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Clinical Services Forms

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These forms can be viewed using Adobe Acrobat (PDFs).

Advanced Directives ( 延命処置 )

Advanced Directives Declaration Form ( 延命処置指示書についての宣言書 )

Advanced Directives ( 延命処置確認 (指示) 書 )

Do Not Resuscitate ( 蘇生処置拒否指示書 )

Living Wills and Durable Power of Attorney ( リビングウィル及び持続的委任状 )

Consent Forms ( 同意書 )

General Consent Form ( 一般同意書 )

Consent to Medical, Surgical, Radiological and other Procedures ( 内科、外科、放射線科およびその他医学的手技の依頼及び承諾 )

Trivalent Influenza Immunization Consent Form ( 三種インフルエンザ予防接種同意書 )

HIV Consent Form ( HIV検査同意書 )

C-Section Consent ( 帝王切開手術同意書 )

HIPPA ( 重要な患者情報・プライバシー )

Imporant Patient Information ( 重要な患者情報 )

OB/GYN ( 産科 )

OB Intake Form ( 妊婦検診問診票 )

Blood Transfusion Information ( 輸血に関する説明書 )

Blood Trasnfusion Consent Form ( 輸血同意書 )

Cesarea Birth - Preoperative Instructions ( 帝王切開手術前の指示書 )

Cesarean Birth Consent Form ( 帝王切開手術同意書 )

Circumcision Consent Form ( 割礼手術同意書 )

Scheduled Induction of Labor Instruction Sheet ( 誘発分娩に関する説明書 )

Sterilization Informed Consent ( 避妊手術承諾書 )

Trial of Labor/ Repeat Cesarean Information ( 帝王切開経験者の出産に関する同意書 )

Pain ( 痛みの管理 )

Pain Management Information for Adult Patients ( 大人の痛みの管理 )

Pain Management Information for Children ( 子供の痛みの管理 )

Patient Rights and Responsibilities ( 患者の権利と義務 )

Brochure available from Patient Relations, 734-936-4330 ( 患者サービス (734-936-4330) にてパンフレットを用意しています )

Other ( その他 )

SARS FAQ ( 重症急性呼吸器症候群 (SARS) よくある質問 )

SARS Patient Information Sheet ( 重症急性呼吸器症候群 (SARS) 患者情報カバーシート )

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Clinical Services Forms



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