Inpatient Absence Disclaimer
Inpatient’s Name: Department: Admission No.: Bed No.:
Going out time: m / d/ y/ Time: Return time: m / d/ y/ Time:
Doctors’ Statement: Inpatient leaving the hospital during his/her hospitalization is strongly prohibited, as it may cause the following risks: 1、
2、
3、
4、
5、
6、 Aggravate or worsen his/her condition Counter against the treatment achievements Miss the best treatment time May not get immediate attention when his/her circumstances change Accidents or medical affairs Other unforeseeable situations.
Doctor on duty: Nurse on duty:
Contact Number:
Inpatient’s Statement:
I fully understand the opinions of ReLife medical staff, and I clearly acknowledge the risks stated above. However, I insist on going out of this facility, and I will take full responsibility for my action. In case of any risks or accidents which may happen to me, it has no relationship with ReLife International Medical Center and medical staff thereof.
I am fully aware that if any emergency occurs during my absence from
Inpatient Absence Disclaimer
this facility, I shall seek help from ReLife International Medical Center immediately, or take any necessary emergency measures on-site.
Inpatient signature: Contact Telephone Number: Date: m/ d/ y/
第二篇:请假条模板 2
请假条
学院:
贵学院 班 同学系校学生联合会 部门(干部/干事),因工作需要,无法参加 月 日 (晚自习/课程学习),特此请假,为感!
湖南工程学院学生联合会
年月日
请假条
学院:
贵学院 班 同学系校学生联合会 部门(干部/干事),因工作需要,无法参加月/课程学习),特此请假,为感!
湖南工程学院学生联合会
年月日
请假条
学院:
贵学院 班 同学系校学生联合会 部门(干部/干事),因工作需要,无法参加 月 日 (晚自习/课程学习),特此请假,为感!
湖南工程学院学生联合会
年月日