Intake Forms- Additional Services July 18, 2011 By Maunalani Staff RESIDENT DENTAL CARE AGREEMENT A. I wish to participate in the dental program of this facility. I understand this involves an oral examination by a licensed dentist. I also understand that I may refuse any further treatment if I so desire. B. I do not wish to obtain an oral examination or participate in the program at this time. Select 'A' OR 'B'IF 'B' WAS CHOSEN, CHECK ONE OF THE FOLLOWING: I have had an oral examination within the past six months and I will provide the facility with written results of this examination. I will be receiving dental treatment while a resident at the facility by my own dentist Select 'A' or 'B'Name of Dentist AUTHORIZATION FOR HAIR SALON SERVICES A. I authorize Maunalani to take care of the scheduling of hair salon services as determined by the charge nurse. Additionally, when hair services are scheduled by the charge nurse, I assume full responsibility for payment of such services. B. I will make other arrangements for hair salon services or will advise charge nurse when hair salon services are needed at Maunalani. Select 'A' OR 'B'Details of hair salon services Additionally, when hair salon services are scheduled by the charge nurse, I assume fidl responsibility for payment of such services.PHOTO RELEASE I authorize Maunalani Nursing Center to use my photograph(s) and/or name for only those purposes indicated below my initials. Any other use of my photograph(s) and/or name is forbidden unless I express my consent at the time the photograph is taken. This consent will end on the date of my discharge.for identification, in-house postings and diagnostic purposes;* Reset signature Signature locked. Reset to sign again Signature of Resident or Responsible Party* Reset signature Signature locked. Reset to sign again Name of Resident or Responsible Party* First Last Date* MM slash DD slash YYYY Share this:FacebookTwitterLinkedIn
