Part 86, page 40

Transcript

The scan is the source; the transcript is machine-generated from it.

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

b6 b7C

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