PATIENT’S DECLARATION

AUTHORIZATION FOR PATIENT CARE: I voluntarily consent to and authorize the rendering of health care services, including routine hospital services, diagnostic procedures, intravenous therapy, medications, injections, laboratory services, and other services or procedures, including the use or potential use of restraint, which my attending physician or others holding clinical privileges consider necessary in person or telehealth. I understand that health care services may be rendered by students, interns under supervision. I further understand that the practice of medicine is not an exact science and I acknowledge that no promises or guarantees have been made to me regarding treatment or services rendered in this health care facility. I acknowledge The Tibabu Health Consultancy (TTHC) facilities and providers do not provide medical aid in dying medication or related services.

INDEPENDENT PRACTITIONERS (SPECIALISTS). I understand that the Hospital may outsource professionals who will provide care to me in the hospital. These professionals may include my own physician, other physicians requested by my physician to participate in my care as well as emergency department physicians, radiologists, pathologists and anesthesiologists. As a result, I understand that these professionals will bill me for charges that are separate from those of the Hospital. I understand that, in some cases these professionals may not be participating providers under my insurance plan. I understand it is my responsibility for out of network costs or other costs because the professional does not have a contract with my insurance plan. I understand that by entering into this Patient-Hospital Contract, I agree and acknowledge that I have personal financial responsibility for any charges or costs not covered by my insurance, if I have any.