)
CONDITIONS    OF   ADMISSIO
k
T O
TEMPLE HOSPITAL
1. General Duty Nursing: The hospital provides only general duty nursing care. Under this system nurses are called
to the bedside of the patient by a signal system, If the patient is in such condition as to need continuous or special
duty nursing care, it is agreed that such must be arranged by the patient, or his legal representative, or his physicians, and the hospital shall in no way be responsible for failure to provide the same and is hereby released
from any and all liability arising from the fact that said patient is not provided with such additional care.
2. Medical and Surgical Consent: The patient is under the control of his attending physicians and the hospital is not
liable for any act or omission in following the instructions of said physicians, and the undersigned consents to any
x-ray examination, laboratory procedures, anesthesia, medical or surgical treatment or hospital services rendered the
patient under the general and special instructions of the physician. The undersigned recognizes that all doctors of
medicine furnishing services to the patient, including the radiologist, pathologist, anesthetist and the like are independent contractors and are not employees or agents of the hospital.
3. Release of Information: The hospital may disclose all or any part of the patient's record to any person or corporation which is or may be liable under a contract to the hospital or to the patient or to a family member or employer
of the patient for all or part of the hospital's charge, including, but not limited to, hospital or medical service
companies, insurance companies, workmen's compensation carriers, welfare funds, or the patient's employer.
4. Personal Valuables: It is understood and agreed that the hospital maintains a safe for the safekeeping of money
and valuables and the hospital shall not be liable for the loss or damage to any money, jewelry, glasses, dentures,
documents, furs, fur coats and fur garments or other articles of unusual value and small compass, unless placed
therein, and shall not be liable for loss or damage to any other personal property, unless deposited with the hospital
for safekeeping.
5. Financial Agreement: The undersigned agrees, whether he signs as agent or as patient, that in consideration of the
services to be rendered to the patient, he hereby individually obligates himself to pay the account of the hospital
in accordance with the regular rates and terms of the hospital. Should the account be referred to an attorney for
collection, the undersigned shall pay reasonable attorney's fees and collection expense. All delinquent accounts
bear interest at the legal rate.
6. Check Out Time: Check out time is 11 a.m. on your going home day. After this you will be charged for another
day.
The undersigned certifies that he has read the foregoing, receiving a copy thereof,  and is the patient, or is duly
authorized by the patient as patient's general agent to execute the above and accept ih terms.
Patient
Patient's Agent or Representative
A copy of this Document is to be delivered to the patient.
_/2r_A.^' „,9<A7 *<jyy.
Relationship to Patient
£ yy>-
Time of signing
Witness	
M_
„Ayj4i^vyi
Form A\