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Form preview Ad904 a form STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Distribution Instructions: Original: Agency/Department Copy: Person Signing CONSENT FOR CONTACT 1. 2.
Form preview Blood pressure consent form Blood Pressure Screening Consent Form To be completed by participant Participant Name Gender Male Female Date of Birth // Company Name Location I hereby consent to blood pressure screening services. I understand that these services are being offered as part of an educational awareness program and results will be provided to my employer in aggregate format only. Signature of Participant Date BP Reading / Please check the most appropriate category based on screening result Ideal 120/80 Moderate Risk 120-139 / 80-89 High Risk 140-159 / 90-99 Extreme 160/100 I hereby confirm the above test results are considered accurate. I understand that these services are being offered as part of an educational awareness program and results will be provided to my employer in aggregate format only. Signature of Participant Date BP Reading / Please check the most appropriate category based on screening result Ideal 120/80 Moderate Risk 120-139 / 80-89 High Risk 140-159 / 90-99 Extreme 160/100 I hereby confirm the above test results are considered accurate.
Form preview Easement consent form Palm Beach County Planning, Building & Zoning Permit Center Building Division Permitting of Structures of Service Systems In Easements To assist you in identifying potential holders, the following
Form preview Outpatient consent form AFFIX PATIENT INFO LABEL HERE Patient Name OUTPATIENT CONSENT FORM MR CONSENT TO CARE I wish to be treated by and/or admitted to Hackensack University Medical Center. I understand that this form will be valid for the period of one year from the date signed for all outpatient services. I also understand that I have the right to ask questions at any time regarding my treatment care of any terms contained on this consent. While I am a patient I give permission to my doctor s the hospital employees and all the persons caring for me to provide care in ways they judge are beneficial to me. I understand that this care may include tests examinations and medical treatments. I understand that the Medical Center is a teaching hospital and that under the appropriate supervision medical students fellows and residents of the University of Medicine and Dentistry of New Jersey Hackensack University Medical Center or other teaching affiliates may participate in my care and treatment but I may decline such participation* The University of Medicine and Dentistry of New Jersey medical students fellows and residents are employees of the state of New Jersey. I understand that no guarantees have been made to me about the outcome of this case. I hereby authorize Hackensack University Medical Center to preserve and use for scientific and/or teaching purposes or dispose of any specimens or tissues taken from my body during hospitalization and hereby waive any clam or right I may have in such specimens or tissues. INDEPENDENT PHYSICIANS I understand and agree that i the physicians who participate in my care and treatment at Hackensack University Medical Ce nter are Independent contractors or private practitioners who have been granted the privilege of using Medical Center facilities for the care and treatment of their patients ii these physicians are not the agent or employee of Hackensack University Medical Center and iii Hackensack University Medical Center is not in any way responsible for the judgment or conduct of any physicians providing medical services at the hospital* While physicians who practice at Hackensack University Medical Center must admitted to the staff and continue to meet certain educational and experience requirements I agree that Hackensack University Medical Center is not responsible for the care provided to me by them* PATIENT RIGHTS I acknowledge that I have received a copy of the New Jersey Patient Bill of Rights and an Advance Directive Brochure. ADVANCED DIRECTIVE Federal and State law require hospitals to ask the following questions of all adult patients being registered to their facility. Do you have an Advance Directive or Living Will for healthcare Yes No N/A Name of Healthcare Proxy If Applicable Was a copy of the document provided at the time of registration RELEASE OF INFORMATION The Medical Center may see release to and/or confirm all or part of any financial and medical information including information regarding psychological psychiatric HIV and related diagnosis drug and/or alcohol related illness with any person corporation or government agency that is or may be responsible to the hospital the patient and family member or employer for all or part of the Medical Center s charges or verification of the same.
Form preview Ohsu flu vaccine consent form All applicants must complete either the Attestation or the Declination Attestation of Influenza Vaccination By my signature below, I attest that I have received the 2010 influenza vaccination from
Form preview Easy english consumer consent... Can we share information about you? You must give us permission before we can give out information about you. 1 Read this form 2 Understand this form 3 Sign this form 1 Your personal information You
Form preview Consent form for the treatment... Education and Research. MC7020-10. I hereby give the Medical/Nursing staff at Mayo Clinic Health System Red Cedar permission to evaluate and treat my.
Form preview Flu shot consent form sandy ci... INFLUENZA VACCINE CONSENT FORM AND ADMINISTRATION RECORD Personal Information (PLEASE PRINT) NAME: BIRTHDATE: AGE: ADDRESS: SEX: M F CITY: STATE: ZIP: I have read or have had explained to me the Vaccine
Form preview Vaccination consent form I certify that I have read or had this Vaccine Documentation and Consent Form 2 pages and the VIS s read and/or explained to me that I fully understand the information in the VIS s and the consents and authorizations given in this Form that I have been given ample opportunity to ask questions about this Form VIS s and the vaccine s selected above and that all questions have been answered to my satisfaction and that I am the Patient listed in this Form or I am duly authorized by the Patient listed in this Form to provide the consents and authorizations described herein and to sign this Form. I acknowledge and agree that the selected vaccination s is/are being administered by Nursing Practice Corporation a Michigan non-profit corporation doing business as Campus Health Center and not by or on behalf of Wayne State University the University or any agent of the University and that no health care provider relationship is being created between the University and the Patient as a result of receiving the selected vaccinations. CAMPUS HEALTH CENTER 5200 Anthony Wayne Drive Suite 115 Detroit MI 48202 313 577-5041 Internal Use Only VACCINE DOCUMENTATION AND CONSENT FORM Patient Name MCIR Yes No DOB First Middle Initial Last MM / DD / YY Address Street City State Zip Code I request consent and authorize Nursing Practice Corporation a Michigan non-profit corporation doing business as Campus Health Center to administer the vaccine s selected below to me or to my minor child or ward listed as Patient on this Form. VIS Date Hepatitis A Human Papilloma Virus HPV Influenza Flu Measles Mumps Rubella MMR Meningococcal Meningitis Polio IPV Pneumococcal Polysaccharide Pneumonia Tetanus and Diphtheria Td Tetanus Diphtheria Pertussis TDaP or DTaP Typhoid Yellow Fever Varicella Chicken Pox IMMUNIZATION SCREENING QUESTIONNAIRE 1. Have you ever had any allergic or adverse reaction to any vaccination If Yes please list Yes No 2. Are you currently taking any medications 5. CAMPUS HEALTH CENTER 5200 Anthony Wayne Drive Suite 115 Detroit MI 48202 313 577-5041 Internal Use Only VACCINE DOCUMENTATION AND CONSENT FORM Patient Name MCIR Yes No DOB First Middle Initial Last MM / DD / YY Address Street City State Zip Code I request consent and authorize Nursing Practice Corporation a Michigan non-profit corporation doing business as Campus Health Center to administer the vaccine s selected below to me or to my minor child or ward listed as Patient on this Form* VIS Date Hepatitis A Human Papilloma Virus HPV Influenza Flu Measles Mumps Rubella MMR Meningococcal Meningitis Polio IPV Pneumococcal Polysaccharide Pneumonia Tetanus and Diphtheria Td Tetanus Diphtheria Pertussis TDaP or DTaP Typhoid Yellow Fever Varicella Chicken Pox IMMUNIZATION SCREENING QUESTIONNAIRE 1. Have you ever had any allergic or adverse reaction to any vaccination If Yes please list Yes No 2. Are you currently taking any medications 5. Do you have an allergy to latex those described above 7. Have you been sick or had a fever of 101 F or higher in the past 48 hours 8.
Form preview Color consent form Color correction -Client Consent Form Corrective hair color is a color process that must be performed by a professional hair colorist to correct any and all damage caused by a color service gone wrong. This could mean something as simple as you wanted to be honey blonde and ended up with platinum blonde hair or something as drastic as a chemical being left on your hair too long and now your hair is breaking off in your hair brush. Another reason you may need corrective color service is if you colored your hair at home and you turned your hair black instead of the warm brown shown on the box. There are many factors as to why a color service goes wrong. For those of you who do it at home you may not realize that your hair is porous and will absorb more color than the average person* If your bad hair color was a result of a salon visit you may have been working with someone inexperienced which can lead to leaving bleach or color on your hair too long. Perhaps the most serious situation which can occur with an inexperienced hair colorist is that they fail to recognize that your hair is too damaged to color correctly in the first place and it needs deep conditioning and rehydration prior to being colored or bleached* All of these reasons and more are why you should always seek a true hair color experts. If you are coming in for a corrective color service HAIR HOLISTIC Salon there are a few things that are important to be aware of before coming to the salon* When a client comes to us for corrective color services she has usually had previous color services performed on her hair which have created an unsatisfactory result* If this is the case for you personally it is important to realize the effect that these previous services may have had on your hair. Your hair is in a stressed and weakened condition when you walk through our door. Because of the caution necessary to perform services on fragile hair it could take several visits to achieve the final result* That is why it is called corrective hair color / Color correction. To set the correct expectations it is important that you pay attention to your colorist advice and ask any questions that may arise during your initial consultation* Please keep in mind that the final result may take several visits to achieve depending on how damaged or weak your hair is upon your first visit for color correction* This is due to the fact that performing all services necessary to correct the color for the desired result may break or further damage your hair if there is not ample time between processes to allow your hair to strengthen* Hair Color Correction will Fix botched home hair color and other color disasters Remove unwanted hues Help restore your hair s health so you can get and keep the color you want Make blonde less brassy Create subtle tonal shifts Lighten or darken your hair or just areas of it such as ends or roots Return your color to its natural shade. Please note that the number of visits cannot always be determined until the process is started* Additionally there is not a set price for corrective color.
Form preview Received flu shot fillable for... CONSENT FORM FOR SEASONAL INFLUENZA VACCINE I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks
Form preview Homeland travel consent form h... INTERNATIONAL STUDENT PROGRAM ? HOMELAND PARENT TRAVEL CONSENT FORM Hastings and Prince Edward District School Board 156 Ann Street, Belleville, Ontario, Canada K8N 3L3 Telephone: 1-613-966-1170 Fax:
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