Common use of Personal Valuables Clause in Contracts

Personal Valuables. The Hospital shall not be liable for loss of, or damage to, property not deposited with it for safekeeping. ( initials date) Communication Assistance: I and/or my companion(s) have been offered Communication Assistance on this date. Accepted ( initials date) ● Declined ( initials date) Notice of Privacy Practices: I have been offered a copy of Xxxxxxx’s Notice of Privacy Practices on this date. Accepted ( initials date) ● Declined ( initials date) Your Patient Rights and Responsibilities/Notice of Nondiscrimination I have been offered a copy of Sentara’s Your Patient Rights and Responsibilities/Notice of Nondiscrimination on this date. Accepted ( initials date) ● Declined ( initials date) EACH UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND FULLY UNDERSTAND THE MEANING AND EFFECTS OF THIS ENTIRE AGREEMENT, AND THAT SENTARA HAS MADE NO REPRESENTATION NOT HEREIN SET FORTH. CARBON COPIES AND PHOTOCOPIES HEREOF ARE DUPLICATE ORIGINALS FOR ALL PURPOSES. Date/Time Patient Signature Other responsible party signature Relationship 🞏 No Responsible Person Available (If checked, two witness signatures required.) 🞏 Patient unable to sign but has acknowledged an understanding of the above and consents to the undersigned witness printing his/her name. 🞏 Verbal consent to treat obtained from responsible party . Employee Witness Signature Date / Time Employee Witness Signature Date / Time

Personal Valuables. The Hospital shall not be liable for loss of, or damage to, property not deposited with it for safekeeping. ( initials date) Communication Assistance: I and/or my companion(s) have been offered Communication Assistance on this date. Accepted ( initials date) ● Declined ( initials date) Notice of Privacy Practices: I have been offered a copy of Xxxxxxx’s Notice of Privacy Practices on this date. Accepted ( initials date) ● Declined ( initials date) Your Patient Rights and Responsibilities/Notice of Nondiscrimination I have been offered a copy of Sentara’s Your Patient Rights and Responsibilities/Notice of Nondiscrimination on this date. Accepted ( initials date) ● Declined ( initials date) EACH UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND FULLY UNDERSTAND THE MEANING AND EFFECTS OF THIS ENTIRE AGREEMENT, AND THAT SENTARA HAS MADE NO REPRESENTATION NOT HEREIN SET FORTH. CARBON COPIES AND PHOTOCOPIES HEREOF ARE DUPLICATE ORIGINALS FOR ALL PURPOSES. Date/Time Patient Signature Other responsible party signature Relationship 🞏 No Responsible Person Available (If checked, two witness signatures required.) � � Patient unable to sign but has acknowledged an understanding of the above and consents to the undersigned witness printing his/her name.  🞏 Verbal consent to treat obtained from responsible party . Employee Witness Signature Date / Time Employee Witness Signature Date / Time

Personal Valuables. The Hospital Sentara shall not be liable for loss of, or damage to, property not deposited with it for safekeeping. ( initials date) Communication Assistance: I and/or my companion(s) have been offered Communication Assistance on this date. Accepted ( initials date) ● Declined ( initials date) Notice of Privacy Practices: I have been offered a copy of Xxxxxxx’s Notice of Privacy Practices on this date. Accepted ( initials date) ● Declined ( initials date) Your Patient Rights and Responsibilities/Notice of Nondiscrimination Nondiscrimination: I have been offered a copy of Sentara’s Your Patient Rights and Responsibilities/Notice of Nondiscrimination on this date. Accepted ( initials date) ● Declined ( initials date) EACH UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND FULLY UNDERSTAND THE MEANING AND EFFECTS OF THIS ENTIRE AGREEMENT, AND THAT SENTARA HAS MADE NO REPRESENTATION NOT HEREIN SET FORTH. CARBON COPIES AND PHOTOCOPIES HEREOF ARE DUPLICATE ORIGINALS FOR ALL PURPOSES. Date/Time Patient Signature Other responsible party signature Relationship 🞏 No Responsible Person Available (If checked, two witness signatures required.) 🞏 Patient unable to sign but has acknowledged an understanding of the above and consents to the undersigned witness printing his/her name. 🞏 Verbal consent to treat obtained from responsible party . Employee Witness Signature Date / Time Employee Witness Signature Date / Time

Personal Valuables. The Hospital Sentara shall not be liable for loss of, or damage to, property not deposited with it for safekeeping. ( initials date) Communication Assistance: I and/or my companion(s) have been offered Communication Assistance on this date. Accepted ( initials date) ● Declined ( initials date) Notice of Privacy Practices: I have been offered a copy of Xxxxxxx’s Notice of Privacy Practices on this date. Accepted ( initials date) ● Declined ( initials date) Your Patient Rights and Responsibilities/Notice of Nondiscrimination Nondiscrimination: I have been offered a copy of Sentara’s Your Patient Rights and Responsibilities/Notice of Nondiscrimination on this date. Accepted ( initials date) ● Declined ( initials date) EACH UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND FULLY UNDERSTAND THE MEANING AND EFFECTS OF THIS ENTIRE AGREEMENT, AND THAT SENTARA HAS MADE NO REPRESENTATION NOT HEREIN SET FORTH. CARBON COPIES AND PHOTOCOPIES HEREOF ARE DUPLICATE ORIGINALS FOR ALL PURPOSES. Date/Time Patient Signature Other responsible party signature Relationship 🞏o No Responsible Person Available (If checked, two witness signatures required.) �o � Patient unable to sign but has acknowledged an understanding of the above and consents to the undersigned witness printing his/her name. o 🞏 Verbal consent to treat obtained from responsible party . Employee Witness Signature Date / Time Employee Witness Signature Date / Time