Common Contracts
2 similar Consent for Treatment & Financial Agreement contracts
Consent for Treatment & Financial Agreement - SMJH & SMJMGConsent for Treatment & Financial Agreement • February 6th, 2019
CONSENT FOR TREATMENT: Martha Jefferson Hospital; d/b/a Sentara Martha Jefferson Hospital or Martha Jefferson Medical Group, LLC. (“Sentara”) accepts the above Patient for diagnostic testing, emergency or inpatient/outpatient treatment/surgery or telehealth services. The undersigned hereby consent(s) to Sentara providing its standard services, telehealth services and supplying or administering all services, supplies, medications (which may be dispensed from an alternate site pharmacy) and anesthesia ordered by Patient’s or Sentara’s physicians/assistants, and to the performance of all procedures they deem advisable, and to the disposal of removed tissues and the use of photography for clinical purposes.
Consent for Treatment & Financial AgreementConsent for Treatment & Financial Agreement • May 25th, 2018
CONSENT FOR TREATMENT: Martha Jefferson Hospital; d/b/a Sentara Martha Jefferson Hospital or Martha Jefferson Medical Group, LLC. (“Sentara” or “Hospital”) accepts the above Patient for diagnostic testing, emergency or inpatient/outpatient treatment/surgery or telehealth services. The undersigned hereby consent(s) to Sentara providing its standard services and supplying or administering all services, supplies, medications and anesthesia ordered by Patient’s or Sentara’s physicians/assistants, and to the performance of all procedures they deem advisable, and to the disposal of removed tissues and the use of photography for clinical purposes.
