TAKING THE PATIENT SAFETY PLEDGE......... This registration will be closed on Sunday evening, September 15th through 17th to prepare certificates for all who pledged and registered to attend the event at 2:00 PM
I/we pledge to encourage our members, residents, staff and community to be involved in their own care and the care of their loved ones by following the 5 points of patient involvement:

1. Maintain a current list of all medications you take and share it with your health care provider and family members (Include over-the-counter medications too);
2. Keep a list of all past and present clinicians, surgeries and procedures (w/ dates) and share it with your clinicians and family members;
3. Prepare a list of all your symptoms and questions and bring it with you to all medical appointments ;
4. Prepare your healthcare proxy and other Advance Directives to make sure your instructions are followed;
5. Develop a support system of trusted family members and friends who will help you advocate for safe care. Offer to help support others with their safe care.
How did you learn about this pledge? From what person, organization, group or business. If an individual shared this representing an organization, group or business, please list that name also.
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How would you like your name to appear on the certificate and be listed on the website?
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Name of person completing this form
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Yes, I am authorized to participate (please initial)
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Approximate number we expect to reach
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Website
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