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Conditions of Registration And Admission
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Patient Self Determination
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Have you executed an Advance Directive?
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Notice of Privacy Practices and Patient Rights And Responsibilities
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I acknowledge that I have received the Facility's Notice of Privacy Practices (Please initial):
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Communication While In The Facility
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I authorize the facility to communicate with the following persons about my care: (Name/Phone Number)
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Relation to Patient
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Second Contact Person: (Name/Phone Number)
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Relation to Patient
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Disclosure and Consent - Medical & Surgical Procedures
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I/We voluntarily request Dr. _____
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...to treat my condition, which was explained to me as:
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I authorize the following procedure(s) to be performed:
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I do/do not consent to use of blood and blood products ad deemed necessary. (Select One)
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I understand that no warranty or guarantee has been made to me as to result or cure. (Please Initial)
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I understand if I am pregnant, I must inform the facility immediately (Please Initial)
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I realize the following risks & hazards may occur with this procedure are:
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Disclosure & Consent - Anesthesia and/or Preoperative Pain Management (Analgesia)
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Check planned anesthesia/analgesia methods
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