Samaritan Healthcare is the chosen medical contractual and athletic training provider of Big Bend Community College Athletics.
The patient named below has been informed of the nature and purpose of his/her hospitalization, treatment, and procedures and is aware of the risk and medical complications that may occur. The patient understands and acknowledges that no guarantee or assurance has been made as to the results that may be obtained. The patient voluntarily concents to the hospitalization, care, treatment, and procedures, which may include routine diagnostic procedures, whether tests or otherwise, in such medical and surgical treatment, including, but not limited to, anesthesia, x-ray procedures, blood tests, and laboratory tests, testing for infectious disease, such as, but not limited to AIDS/HIV, as the attending practitioner(s) or other consulting practioner(s) consider to be necessary. For obstetrical admissions, this consent also applied to newborn care and treatment.
The patient understands that the practitioner on the staff of this hospital, including the attending practitioner(s) named on the face sheet may be employees or agents of the hospital or, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, the patient realizes that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education.
In the event a healthcare worker is exposed to my blood or body fluid in a manner that may pose a risk for transmission of a blood-borne infection during this hospitalization, I am giving my consent to be tested for HIV. Testing for HIV, Hepatitis B, and Hepatitis C will be done at no cost to me, so the healthcare worker can be treated promptly. I authorize release of the information to the exposed healthcare worker, his/her healthcare provider and employee health staff.