CONSENT TO ADMISSION AND TREATMENT I hereby consent to my admission to ______________.

I authorize ____________, its medical staff, nursing staff and other Hospital personnel to provide care and administer such diagnostic, radiological and/or therapeutic procedures and treatments as the medical staff determines is necessary or advisable in my care or, for obstetrical patients, in the care of my baby. If a healthcare worker involved in my care and treatment becomes exposed to certain bodily fluids resulting in the possibility of transmission of a bloodborne disease, my blood will be tested for HIV, hepatitis B and hepatitis C to determine risk of exposure to the healthcare worker. I acknowledge that this form authorizes release of my HIV, Hepatitis B and Hepatitis C results to the health care worker accidentally exposed to my blood and their health professional for purposes of providing post-exposure care. I understand that these individuals are prohibited by law from re-disclosing my testing results in a way that could reveal my identity. I understand that if I have provided Emergency Contact names that the Hospital considers these individuals as my Designated Representative(s). The Hospital may share my protected health information (PHI) with my Designated Representative(s) to the extent permitted by law and to the extent that I have directed otherwise. Patient/Agent/Relative/Guardian* (Signature) Date / Time Print Name Relationship if other than patient Telephonic Interpreters ID # OR Signature: Interpreter Print: Interpreters Name and Relationship to Patient Witness to signature (Signature) Date / Time Print Name Release When Patient Leaves Hospital Against Medical Advice I, __________ , request that ___________ (patient/agent/parent or guardian) (myself or name of patient) be discharged from the care of the Hospital. I acknowledge that this request is against the advice of the doctor in charge of (the, my) care and that the danger involved has been explained to me. Therefore, I agree to hold the Hospital, all its officers, employees and medical staff, free from liability for any injury that may result directly or indirectly by reason of said removal.

Physicians Certification When Patient Leaves Hospital Against Medical Advice I hereby certify that I have explained the risks of, and alternatives to, the patient leaving the Hospital against medical advice. I have offered to answer any questions and have fully answered all such questions. I believe that the patient/agent/relative/guardian fully understands what I have explained and answered. Physicians Signature: Date / Time Print Responsible Practitioners Name * The signature of the patient must be obtained unless the patient is an unemancipated minor under the age of 18 or is otherwise incapable of signing.