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Out on Pass Application Form

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Kevin Yu
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688 views2 pages

Out on Pass Application Form

Uploaded by

Kevin Yu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

OUT ON PASS FORM

Date: Time :

l, the undersigned Mr./Mrs./Miss:

Request your permission to go out on pass


temporarily for personal reasons on my own
responsibility knowing that the hospital is not
responsible for whatever happens to me outside the
hospital.

I assume full responsibility for adverse outcome


related to this risk.

Retained medical devices?


IV cannula: Yes No
Drains Yes No
Others, Yes No Specify:

Patient/Relative Signature:
Contact Tel. No.:
Time / Date left from hospital.
Time / Date returned to hospital

Out on Pass Approved by


Name of MRP:

Signature:
Recommendations/Special Instructions as per MRP advice: :

Patient's relative informed: Yes No

Witness
Name of Witness:

Signature:
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