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1 ~Blank Consent/Vendor/Student Form Carolinas Hospital System consent for Operation and/or Procedure Acknowledgement conditions may occur during the operation and/or procedure. In signing below, I give consent(s):_________________________________________________________________________________ (State exception(s) or “none”) consent: I give consent for the following operation http://dev.medxnet.net/Documents/MedXnetFinalPDF/2456.pdf       Content Match

2 Photography Media Consent Carolinas Hospital System Florence, South Carolina Photography/Media consent form I hereby consent and authorize Carolinas Hospital System and the attending physician - 072007 (consents – Photography/Media consent) consent to Photograph/Video Tape/Film http://dev.medxnet.net/Documents/MedXnetFinalPDF/2183.pdf       Content Match

3 ~Preoperative Teaching Surgical Checklist :_____________ Nurse Initials:_______________ Tab: consent/OR/Other Surgical Checklist Yes No N/A History and Physical on Record Surgical consent (s) Anesthesia consent (s) Identification Bracelet NPO since (time) Label http://dev.medxnet.net/Documents/MedXnetFinalPDF/2503.pdf       Content Match

4 Anesthesia Patient Education Consent Carolinas Hospital System South Carolina Patient Education consent certify that I have read this form or had it read to me. _________________________________ _____________________________________________________________ (Date) Anesthesiologist and/or Anesthetist Obtaining consent http://dev.medxnet.net/Documents/MedXnetFinalPDF/2492.pdf       Content Match

5 Refuse - Informed Consent to Refuse Informed consent To Refuse Examination/Treatment Informed consent I understand was offered but refused to sign the form after explanation of their rights and the risks - 071107 (consents – Informed consent to refuse http://dev.medxnet.net/Documents/MedXnetFinalPDF/2290.pdf       Content Match

6 Release of Confidential Information for Bruce Hall will be released in the following form: Written Verbal Audio Electronic (including fax CFR, Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at anytime except to the extent http://dev.medxnet.net/Documents/MedXnetFinalPDF/2617.pdf       Content Match

7 Release of Confidential Info General for Bruce Hall form: ‰ Written ‰ Verbal ‰ Audio ‰ Electronic (including fax) ‰ Other, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at anytime except to the extent that action http://dev.medxnet.net/Documents/MedXnetFinalPDF/2618.pdf       Content Match

8 Florence OBGYN Ass. GYN Admit 1 2 3 4 Diet: Reg ( ) 5 Activity: 6 7 8 9 10 11 12 13 Sign consent form: Physician' s Orders – 6/a - 02/20/2008 (Chapman GYN Admit) Up Ad lib ( ) Bed Rest with Bathroom Privileges ( ) Bed Rest ( ) Admit http://dev.medxnet.net/Documents/MedXnetFinalPDF/2831.pdf       Content Match

9 Peritoneal Dialysis in the case of a medical emergency. This consent form must contain the following nine items: i. name complete a Verbal Information Release Telephone and Visiting consent form. 2. A staff member determines and Visiting consent form and having the Patient Identification Number are given information or allowed http://dev.medxnet.net/Documents/MedXnetFinalPDF/2940.pdf       Content Match

10 Jackson OB_Admit_Labor _________________ Sign consent form Pain Medications: Catheterize PRN if unable to void Carolinas Hospital http://dev.medxnet.net/Documents/MedXnetFinalPDF/2860.pdf       Content Match

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