INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 I understand that while the facility will be responsible for items deposited in the safe, I must be responsible for all itemsretained by me at the bedside. (Dentures kept the bedside will be labeled, but the facility cannot assure responsibility forthem.) I also recognize that the hospital cannot be held responsible for items brought in to me after this form has beencompleted and signed.Reviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:36:44 PM ESTSignature of Parent or Guardian of PatientReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:37:00 PM ESTSignature of WitnessI have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility responsible for any othermoney or valuables that I am retaining or will have brought in to me. I have been advised that it is recommended that Iretain no more than $5.00 at the bedside.Reviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:36:59 PM ESTSignature of Parent or Guardian of PatientReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:38:28 PM ESTSignature of WitnessI have deposited valuables in the facility safe. The envelope number is .Signature of PatientSignature of Person Accepting PropertyI understand that medications I have brought to the facility will be handled as recommended by my physician. This mayinclude storage, disposal, or administration.Signature of PatientSignature of WitnessGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234