About Us

Ask your physician to read and sign this document, and to place a signed copy of this document in your chart or medical record. Also, have your attorney file the original, and you should also keep a copy in your files. The Second Amendment Sisters came about when a group of women decided they had had enough: Enough of the distortion, enough of the misrepresentation, enough of the reproach from the anti-Second Amendment crowd.

Physician or Educator
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Our Mission
Second Amendment Sisters, Inc. is a women's advocacy group dedicated to preserving the basic human right of selfdefense, and to giving attention to the vital role the Second Amendment of the United States Constitution plays in protecting that right. We believe in personal responsibility and enforcement of laws against violent criminals, and we believe in education over legislation. Most importantly, we believe that safety is a personal choice. Wishing you health, wealth, happiness, and the wisdom to enjoy them! -SAS You know that your first instinct is for survival, and that self-defense is one of your most basic human rights. Join, support, email, respond, or Just talk about the

Qualifications and Liability Statement

Second Amendment Sisters

900 RR 620 S Suite C101 PMB 228 Lakeway TX 78734 www.2asisters.org inquire@2asisters.org 1-877-271-6216

Physician or Educator Qualifications and Liability

For Physician Initial one, as appropriate:

______I represent that I have reviewed applicable scientific literature pertaining to defensive gun use, safety, storage, and beneficial results of private firearms ownership. I further represent that I have reviewed all other home safety issues with the Patient, including those relating to drains, disposals, compactors, doors, driveway safety, pool safety, pool fence codes and special locks for pool gates, auto safety, gas, broken glass, stored cleaning chemicals, buckets, toilets, sharp objects, garden tools, home tools, power tools, lawnmowers, lawn chemicals, scissors, needles, forks, knives, etc. I also acknowledge that by receiving this document. I have been made aware that, in his inaugural address before the American Medical Association on June 20, 2001, new president Richard Corlin, MD, admitted "What we don't know about violence and guns is literally killing us . . . researchers do not have the data to tell how kids get guns, if trigger locks work, what the warning signs of violence in schools and at the workplace are, and other critical questions due to lack of research funding." (UPI). In spite of this admission, I represent that I have sufficient data and expertise to provide expert and clinically sound advice to patients regarding firearms in the home. or ___ I am knowingly engaging in Home/Firearms Safety Counseling without certification, license or formal training in Risk Management, and; I have not reviewed applicable scientific literature pertaining to defensive gun use, safety, storage, and beneficial results of private firearms ownership.

Part Two: Liability

I have determined, from a review of mv medical malpractice insurance, that if I engage in an activity for which I am not certified, such as Firearms Safety Counseling, the carrier (check one as appropriate): ___will ___ will not cover lawsuits resulting from neglect, lack of qualification, etc. Insurance Carrier name, address and policy number insuring me for firearms safety expertise: ___________________________________ ___________________________________ I further warrant that, should the Patient follow my firearm safety counseling and remove from the home and/or disable firearms with trigger locks or other mechanisms, and if the patient or a family member, friend or visitor is subsequently lnjured or killed as a result of said removal or disabling, that my malpractice insurance and/or personal assets will cover all actual and punitive damages resulting from a lawsuit initiated by the patient, the patient's legal representative or the patient's survivors. Signature of attesting physician and date: Name of attesting physician (please print):

Firearms Safety Counseling Representation: Physician Qualifications and Liability

Part One: Qualifications

I, _______________________________ affirm that I am certified to offer my patient __________________________________ hereafter referred to as "the Patient," qualified advice about firearms safety in the home, having received the following training (specify course(s) of study): ___________________________________ ___________________________________ From (specify institution(s)): ___________________________________ ___________________________________ On (specify course completion date(s)): ___________________________________ ___________________________________ Resulting in (specify accreditation(s), certification(s), license(s) etc.): ___________________________________ ___________________________________

___________________________________ ___________________________________
Signature of patient and date:

___________________________________ ___________________________________ Name of patient (please print): ___________________________________ Patient should indicate if physician REFUSED TO SIGN by initialing here:_____