NVDH treatment authorization and release forms for Jack Coffelt
Title revised to match the document’s own text.
Original title: NVDH treatment authorization and release forms signed by Jack Coffelt
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Id: Cooper-Part-86:040-040
Subject: Cooper Files: Cooper-Part-86:040-040 Document: NVDH treatment authorization and release forms for Jack Coffelt Id: Cooper-Part-86:040-040 Page: https://cooper.theunsolved.net/documents/Cooper-Part-86%3A040-040 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 86 p. 40 (DB Cooper-37884), Form — cooper.theunsolved.net/documents/Cooper-Part-86%3A040-040
NORTHERN VIRGINIA DOCTORS HOSPITAL
I (XXXXXX), HEREBY AUTHORIZE THE PERFORMANCE OF ANY MEDICAL PROCEDURE WHICH MAY BE ADVISED AND RECOM[MENDED] BY [illegible] ATTENDING PHYSICIAN OF MYSELF, JACK COFFELT . A PATIENT AT NORTHERN VIRGINIA DOCTO[RS] HOSPITAL. FURTHERMORE, I [DIRECT/DO] RESPECTFULLY REQUEST THE USE OF ANY WHICH [illegible] OR [BENEFICIAL] IN THE PERFORMANCE WITNESS _______________ DATE _______________
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RELEASE FORM RESPONSIBILITY FOR ABORTION
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I, THE UNDERSIGNED, A PATIENT APPLYING FOR ADMISSION TO NORTHERN VIRGINIA DOCTORS HOSPITAL, [BELIEVE] THAT I AM IN A CON[DITION] ABORTION. I HEREBY DECLARE THAT NEITHER THE ATTENDING PHYSICIAN NOR ANY PERSON EMPLOYED BY OR CONNECTED WITH THE SAID HOSPI[TAL] HAS KNOWINGLY PERFORMED ANY ACT WHICH MAY HAVE CONTRIBUTED TO THE INDUCTION OF THE ABORTION DATE_______________ WITNESS_______________ SIGNED_______________ PATIENT_______________ WITNESS_______________
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RELEASE FROM RESPONSIBILITY FOR DISCHARGE
I, THE UNDERSIGNED, DEMAND THE RELEASE OF _______________ NORTHERN VIRGINIA DOCTORS HOSPITAL AND ASSUME FULL RESPONSIBILITY FOR HIS OR HER DISCHARGE AGAINST THE ADVICE OF THE ATTEN[DING] PHYSICIAN AND OF THE HOSPITAL ADMINISTRATION. I ACKNOWLEDGE THAT I HAVE BEEN INFORMED OF THE RISK INVOLVED AND HEREBY RELEA[SE] THE ATTENDING PHYSICIAN AND THE HOSPITAL FROM ALL RESPONSIBILITY FOR ANY ILL EFFECTS WHICH MAY RESULT FROM SUCH DISCHARGE. DATE_______________ WITNESS_______________ SIGNED_______________ WITNESS_______________ RELATIONSHIP TO PATIENT
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ABSENCE PERMIT
I, _______________ A PATIENT IN NORTHERN VIRGINIA DOCTORS HOSPI[TAL] FIND IT NECESSARY TO LEAVE THE HOSPITAL TEMPORARILY, I AM FULLY AWARE THAT WHATEVER ILLNESSES AND OR INJURIES WHICH MAY BEF[ALL] ME DURING MY ABSENCE SHALL NOT BE THE RESPONSIBILITY OF THE PHYSICIAN IS IN CHARGE, THE HOSPITAL, OR ANYONE CONNECTED WITH [THE] HOSPITAL.
I REALIZE FURTHER THAT EMERGENCY ADMISSIONS TO THE HOSPITAL MIGHT NECESSITATE THE USE OF MY HOSPITAL [BED].
DATE_______________ WITNESS_______________ SIGNED_______________ WITNESS_______________
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DB Cooper-37884
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IN THE CASE OF MINOR CHILDREN THIS SECTION MUST BE COMPLETED BY THE PATIENT, GUARDIAN OR OTHER RESPONSIBLE PERSON
Serials: 28887