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October 2017
Brand GuidelinesJefferson Health | October 2017 | Jefferson.edu/Brand
HOME OF SIDNEY KIMMEL MEDICAL COLLEGE
October 2017
Contents
1. BRAND IDENTITY Brand Elements ...........................................1
Scale + Space ...............................................3
Color Formats ............................................. 4
Incorrect Use ................................................5
Donor Acknowledgment .......................... 6
Typography ...................................................7
Color Palette ............................................... 9
Imagery ...................................................... 10
2. BRAND APPLICATION Stationery ................................................... 12
Letterhead
Business Cards/Appointment Cards
Envelopes/Mailing Labels
Buck Slips/Note Pads
Forms ...........................................................17
Prescription Slips ...................................... 18
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October 2017
1. Our Brand IdentityOur core brand elements set the foundation for the Jefferson Health visual identity system. This combination of elements — including logo, typography, color palette, imagery, illustration and other entity logos — helps us to powerfully and uniquely express the Jefferson personality. Used consistently, these elements help us to differentiate our brand in a highly competitive market and create preference in the hearts and minds of our audiences.
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StructureOur logos are the simplest, most immediate and recognizable representation of our brand. They combine nearly two centuries of Jefferson history with a contemporary look. Each communicates a confident and renewed energy that represents our future.
All Jefferson Health logos are composed of the symbol and a wordmark. This shared structure unifies us in the eyes of the consumer.
Registration NoticeThe ® or TM must always appear with the Jefferson logo file as supplied by Creative Services and should never be removed or altered.
Brand Elements
CLINICAL BRAND
symbol wordmark
logo
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Lock-Up SizeA unified brand appearance is essential for our new modern look and feel. The use of consistent logo sizes on all communication materials will establish and maintain this objective. The size of the logo is based on a percentage of the electronic art file supplied by Creative Services.
The preferred logo size is 100%. This is the appropriate size for most hand-held items. On larger pieces, the logo may be used at 125%. No other sizes are permissible on printed pieces without approval from Creative Services.
Larger sizes may be used for banners and signage.
On especially small items, such as give-aways, the logo may be used as small as 60%. If the imprint area won’t allow for the minimum size logo, type may be used instead. Please see section of acceptable typeface options.
Clear SpaceTo uphold recognition and clear legibility of the logo, a minimum amount of clear space based on ½ height of the symbol must be left around the logo. See the diagram at right for specific guidelines for clear space.
This area must be maintained as the protected area between the logo and all other elements, including: type, busy photography, illustrations, page trim, color breaks, etc.
Jefferson department, program, and entity names must not be placed in proximity to the logo so as to suggest that they are part of the logo. If necessary to include, these names must be completely separate from the logo.
The name in the logo must never be repeated in the headline or other prominent feature of the piece.
The Jefferson logo is a legally owned trademark and cannot be used with non-Jefferson logos without prior approval. Please visit Creative.Jefferson.edu to request approval.
Scale + Space
½ the symbol (head) height
100% (preferred size)
LOCK-UP SIZE
CLEAR SPACE
Because all Jefferson Health logos share the same symbol, the same Clear Space guidelines apply to all. See examples.
60% (minimum size)
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Consistent Logo VisibilityPeople tend to notice visuals before they ever read a word. That’s why it’s critical for our logo to always be used precisely in both positive and reverse forms. Select positive or reverse artwork for achieving the best contrast between the logo and background, regardless of background color. Backgrounds include not only printed or applied color, but also colored paper stock, plastics, fabrics or video.
The full color logo on a white background is the preferred version. When applying the logo to a PMS 282 background the full color negative (reverse) logo is preferred. 1 color version of the logo may be used only when reproduction methods will not allow for full color usage (e.g. silk-screen printing, embroidery and certain inter-office applications).
Color Formats
Full Color Preferred Positive
Full Color Preferred Reversed
1 Color PMS 282 (only for use on small-run spot color materials)
1 Color PMS 2915 (only for use on small-run spot color materials)
1 Color Black (only for use on small-run 1-color materials)
1 Color White (only for use on small-run spot color materials)
Color formats are the same for all Jefferson Health logos.
POSITIVE
NEGATIVE (REVERSED)
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Visual identity is an important component of every successful brand. To preserve the integrity and the legal protection of the trademark, it’s critical that we all recognize and understand when an application is unacceptable. While not a complete list, the examples here are a sampling of logo misuses, which work against our brand building efforts. Under no circumstances are any of these examples acceptable in the marketplace.
Incorrect Use
DO NOT add department/program name, phone numbers or address.
NO DECAPITATION! Never separate the head symbol from the logo.
DO NOT use multiple logos together. Use the enterprise or appropriate flagship logo instead.
DO NOT use previous Jefferson logos
DO NOT use only the wordmark.
DO NOT create a new logo by using the symbol with other text.
DO NOT use the logo on backgrounds that do not provide proper contrast.
Center for Medical Treatment
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OverviewThe Sidney Kimmel Donor Acknowledgment Line is intended to promote and create awareness of Sidney Kimmel Medical College (SKMC), brand the nexus of Jefferson and SKMC and acknowledge the donor gift. All communication, in whatever form, of Jefferson shall include the line “Home of Sidney Kimmel Medical College.” The Line must be used in Enterprise, TJU and Jefferson Health level communications, with the message being that Jefferson is the home of Sidney Kimmel Medical College.
COMPLIANCE IS REQUIRED PER THE DONOR AGREEMENT.
ExemptionsThese Supporting Brands would not utilize this donor acknowledgment line: • Jane and Leonard Korman Respiratory Institute • Jefferson Health | Nemours duPont Pediatrics • Marcus Institute of Integrative Health • Rothman Institute at Jefferson • Sidney Kimmel Cancer Center • Vickie and Jack Farber Institute for Neuroscience
Some Examples of Implementation• printed and electronic communication • stationery • advertising • signage • websites
Kimmel Donor Acknowledgment Requirement
H O M E O F S I D N E Y K I M M E L M E D I C A L C O L L E G E
(R)EVOLUTION
JeffersonHealth.org
Transforming the patient experience and giving you accessible
and a ordable care — when and where you need it most.
Providing treatment options informed by some of the region’s most
experienced and renowned specialists — across 13 respected hospitals
and more than 50 outpatient and urgent care locations.
INTRODUCING
Je erson Cherry Hill Hospital | Je erson Stratford Hospital
Je erson Washington Township Hospital
NOW JOINING
Abington Hospital – Je erson Health | Abington – Lansdale Hospital – Je erson Health
Je erson Bucks Hospital | Je erson Frankford Hospital | Je erson Torresdale Hospital
Je erson Hospital for Neuroscience | Methodist Hospital – Je erson Health
Physicians Care Surgical Hospital | Rothman Orthopaedic Specialty Hospitals
Thomas Je erson University Hospital
KENNEDY HEALTH IS NOW JEFFERSON HEALTH
JeffConnect™ is Here for You 24/7
FREE to Employees and Their DependentsOn-Demand Doctor Visits via Your Computer or Mobile Device
Starting October 1 You and your dependents have FREE use of our new
JeffConnect On-Demand Virtual Care telehealth service
until December 31, 2015.
Available 24 Hours a Day/Seven Days a Week Schedule a JeffConnect On-Demand Virtual Care video
visit with a Jefferson doctor using your computer, tablet
or smartphone from anywhere within PA, NJ or DE.
The Fast, Convenient Way to See a Doctor Common uses for JeffConnect video visits include:
• Sinus infections • Urinary Tract Infections
• Bronchitis • Upset stomach
• Flu • Minor skin wounds
• Sore throat • Rashes
• Allergies
Register Now for Access to JeffConnect’s On-Demand Virtual Care
Download the free JeffConnect app today:
The screen to the right appears when you are in App Store, giving you the option to download the app.
Or use your computer to enroll at Jefferson.edu/JeffConnect
Get Started for Free
1. Employees who download and register with JeffConnect by December 31 will automatically be entered into a drawing to win a fitbit®, a wearable activity tracker designed to help you lead a healthier lifestyle. Download the app at:
2. Each time you or your dependents initiate a virtual visit, enter coupon code JeffFamily in order to have your fee waived until December 31, 2015.
3. If you are using a computer for your virtual visit, make sure your computer has a webcam so the doctor can see you during the call.
For employee FAQs about the service, visit the BING.
Get it on
CS 16-0452
Get it on
HOME OF SIDNEY KIMMEL MEDICAL COLLEGE
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October 2017
Typography: Primary
Museo SansThe typeface to be used expressly for Jefferson is Museo Sans. All text in publications, advertising, signage and other external communication materials should be set in Museo Sans. This typeface is modern and easy to read, and comes in a wide range of styles and weights, making it incredibly versatile.
Limited Use AlternateFor business communication (the body of a letter, spreadsheets, etc.) and on approved Jefferson templates, Trebuchet may be used. It is not for situations that require custom design. Trebuchet has been chosen because of its clarity both on-screen and in printed correspondence. It is widely available on both Mac and PC-based computers.
MUSEO SANS 100
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 100 ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 300
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 300 ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 500
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 500 ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 700
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 700 ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 900
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?MUSEO SANS 900 ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?
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Typography: Complementary
ITC CenturyThis complementary typeface is primarily used as accent and for body text on long passages. All weights and styles are approved for use.
Museo SlabThe display typeface Museo Slab contrasts and coordinates nicely with both Museo Sans and ITC Century, and may be used sparingly as an accent.
Limited Use Alternate SerifGeorgia may be used for business communications (the body of a letter, spreadsheets, etc.). It is not for situations that require custom design. Georgia has also been designed for clarity on computer monitors, even at small sizes. It is also well suited for laser-printed output. Like Trebuchet, it has been chosen for its wide availability on both Mac and PC-based computers.
ITC CENTURY LIGHT
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz 1234567890!@#$%^&*()_+?ITC CENTURY LIGHT ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY BOOK
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY BOOK ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY BOLD
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY BOLD ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY ULTRA
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?ITC CENTURY ULTRA ITALIC
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz1234567890!@#$%^&*()_+?
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Color Palette
PMS 241 C33 M100 Y0 K0 R175 G31 B142
Hex af1f8e
PMS 250 C7 M28 Y0 K0
R230 G191 B218 Hex e6bfda
PMS 242 C33 M100 Y9 K45
R112 G0 B95 Hex 700052
PMS 319 C62 M0 Y20 K0 R77 G196 B207
Hex 4dc4cf
PMS 406 C5 M8 Y10 K16
R205 G198 B193 Hex cdc6c1
PMS 628 C20 M0 Y5 K0
R200 G233 B239 Hex c8e9ef
PMS 730 C30 M60 Y95 K16 R160 G103, B45
Hex a0672d
PMS 612 C7 M5 Y100 K22 R195 G182 B13
Hex c3b60d
PMS 410 C22 M33 Y27 K62
R98 G84 B84 Hex 625454
PMS 616 C10 M4 Y49 K6
R218 G214 B144 Hex dad690
PMS 5825 C22 M15 Y86 K55
R110 G107 B35 Hex 6e6b23
PMS 179 C0 M89 Y84 K0 R239 G68 B56
Hex ef4438
PMS 169 C0 M31 Y25 K0
R250 G188 B174 Hex fabcae
PMS 727 C13 M30 Y46 K0 R221 G179, B140
Hex ddb38d
PMS 130 C0 M35 Y100 K0 R252 G175 B23
Hex fcaf17
PMS 134 C0 M12 Y60 K0 R255 G221 B127
Hex ffdd7f
PMS 1205 C0 M2 Y28 K0
R255 G244 B195 Hex fff4c3
PMS 2727 C76 M50 Y0 K0 R70 G120 B188
Hex 4678bc
PMS 2706 C19 M13 Y0 K0
R201 G209 B235 Hex c9d1eb
PMS 656 C12 M6 3 K0
R221 G228 B236 Hex dde4ec
PMS 2915 C60 M10 Y5 K0 R89 G183 B223
Hex 59B7DF
PMS 282 C100 M90 Y25 K40
R1 G30 B64 Hex 152456
Jefferson Deep Blue Jefferson Bright Blue
Brand Foundation ColorsColor is a critical identifier of the new contemporary Jefferson. Inspired by our new vision, the overall theme of our colors is smart, energetic and vibrant.
The primary colors for our brand are Jefferson Dark Blue and Jefferson Bright Blue. Primary colors must be used in all communications and can be supported with neutral and/or accent colors.
Accent ColorsOur color palette allows for great flexibility. We chose these accent colors to bring life to the new Jefferson. These colors provide a vibrant, passionate and optimistic tonality when used in combination with the Jefferson Brand Foundation colrs.
Pantone®, CMYK, and RGB equivalents are specified here in order to maintain consistency across all Jefferson communications.
EmbroideryJEFFERSON DEEP BLUE Robison-Anton Super Brite® Polyester RA #122: 5739 Blue Ribbon or Madeira Polyneon 1967 Dark Denim
JEFFERSON BRIGHT BLUE Robison-Anton Super Brite® Polyester RA #122: 9039 Blue Splendor or Madeira Polyneon 1871 Porcelain Blue
ACCENT COLORS
BRAND FOUNDATION COLORS NEUTRAL COLORS
October 2017
Imagery: Photography
Overall Tone and FeelPhotography serves as a powerful, emotional attachment to our audience. It should be spontaneous, dynamic, active, optimistic, warm, bright, spirited and naturally lit when possible. When appropriate, nature should be used to capture our spirit of growth, openness and optimism. Empty public spaces should not be shown.
Diversity and InclusionEvery attempt must be made to reflect the rich diversity of our students, staff and the communities we serve.
Dynamic MovementJefferson Health is an organization in perpetual motion. For this reason, our photos should always be active and engaging. By using a motion blur effect where appropriate, we highlight our positive energy and our progressive thinking. Images that show empty public spaces should never be used.
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Imagery: Illustration
When medical illustrations are used, they should support that Jefferson is at the forefront of medical technology by being clear, dynamic and cutting-edge.
For custom illustrations, contact: Medical Media Services jeffline.tju.edu/MMS 215-503-7841
Creative Services Creative.Jefferson.edu
What To AvoidIllustration should be used for diagrams and medical explanation. It should never be substituted for photography. Cartoon-like or poor quality graphics, inconsistent styles, and “spot” illustrations are not appropriate.
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2.Our Brand in Action
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Stationery: Letterhead
Home of Sidney Kimmel medical college
John Smith, MDDirector, Medicine Programs Department of Medicine
1200 Old York Road Abington, PA 19001T 215-481-2000F [email protected] abingtonhealth.org
Minimal and modern, our letterhead is formatted as shown in the example at right. To ensure consistency in our branding, Jefferson stationery items can only be ordered via the link below, and may not be recreated, produced or printed by any other means. To order, please visit Creative.Jefferson.edu.
The Sidney Kimmel Donor Acknowledgment line will automatically be included when appropriate.
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October 2017
Stationery: Business/Appointment Cards
Minimal and modern, our business cards are formatted as shown in the examples at right. To ensure brand consistency, Jefferson stationery items can only be ordered via the link below, and may not be recreated, produced or printed by any other means. To order, please visit Creative.Jefferson.edu.
The Sidney Kimmel Donor Acknowledgment line will automatically be included when appropriate.
Home of Sidney Kimmel medical college
John Smith, MDDirector, Medical Programs Department of Medicine
1200 Old York Road, Abington, PA 19001T 215-481-2000 F [email protected] abingtonhealth.org
NameTitle/Department
123 Street Avenue, Suite 456 Your City, PA 12345T 123-456-7890 F [email protected] Jefferson.edu
NameTitle/Department
123 Street Avenue, Suite 456 Your City, PA 12345T 123-456-7890 F [email protected] Jefferson.edu
123 Street Avenue Suite 456 Your City, PA 12345T 123-456-7890 F 123-456-7890
4567 Road Highway Suite 456 Different City, PA 34567T 223-456-7891 F 123-456-7892
Business Card
Appointment Card Front
Appointment Card Back
☐ M ☐ T ☐ W ☐ TH ☐ F ☐ S
APPT DATE APPT TIME
Please telephone one day in advance if you will be unable to keep the appointment.
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October 2017
Stationery: Envelopes/Mailing Labels
Minimal and modern, our envelopes and mailing labels are formatted as shown in the examples at right. To ensure consistency of our brand, Jefferson stationery items can only be ordered via the link below, and may not be recreated, produced or printed by any other means. To order, please visit Creative.Jefferson.edu.
Department Name 123 Street Avenue, Suite 456 Your City, PA 12345
Department Name 123 Street Avenue, Suite 456 Your City, PA 12345
Department Name 123 Street Avenue, Suite 456 Your City, PA 12345
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October 2017
Stationery: Buck Slips/Note Pads
Minimal and modern, our letterhead is formatted as shown at right. To ensure consistency in our branding, Jefferson stationery items can only be ordered via the link below, and may not be recreated, produced or printed by any other means. To order, please visit Creative.Jefferson.edu.
The Sidney Kimmel Donor Acknowledgment line will automatically be included when appropriate.
123 Street Avenue, Suite 456 Your City, PA 12345T 123-456-7890 F 123-456-7890 [email protected]
NameTitle/Department
To Date
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October 2017
Forms
Forms often have specific technical requirements that make their standardization difficult. Nonetheless, every effort should be made to create a common look for forms. A sample layout for forms is shown here.
For new or revised forms, please visit Creative.Jefferson.edu. Medical Records should be submitted to the Director of Health Information Management, 2130 Gibbon Building. To search the Jefferson Forms Library, visit: tjuh.jeffersonhospital.org/forms
Procedure Consent Form
*015600.0609*
MR#
Acct#
Name
DOB
COMPLETE OR IMPRINT WITH ADDRESS-O-PLATE
FORM 0156-00 (REV. 06/09) PAGE 1 OF 2
IMP
OR
TA
NT
: DO
NO
T W
RIT
E I
N M
AR
GIN
S
1. I hereby authorize Dr.(s) to perform upon
(Patient Name) the following surgical and/or medical procedures: (State specific nature of the procedure(s) to be performed and describe its benefits
and likelihood of achieving treatment goals)
2. I authorize the following device(s) to be implanted during the above named procedure(s). (Describe type of device/implant):
3. I understand that the procedure(s) will be performed at Thomas Jefferson University Hospitals, Inc. by or under the supervision of the attending physician. He/She is authorized to utilize the services of such other health care professionals and trainees, including physicians and members of the house staff, as he/she deems necessary or advisable in the performance of the procedure(s) listed above. I understand that Thomas Jefferson University Hospital is an academic medical center and that students and trainees may be participating in my care, under appropriate supervision.
4. I understand that, during the course of the surgical procedure(s), unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedures than those set forth in Paragraph 1 above. I authorize and request that the above-named surgeon, his/her assistants, or his/her designees perform such surgical procedures as are necessary and desirable for my medical condition in the exercise of their professional judgment.
5. I acknowledge that the available anesthesia options have been explained to me along with their respective benefits and risks. I consent to the administration of the following type of anesthesia/sedation to be applied by or under the direction of my physician:
M Moderate Sedation (“Conscious Sedation”) M Local Anesthesia
6. If my physician determines that other anesthesia is necessary, a physician member of the Anesthesiology Department will obtain consent for any additional anesthesia required. I understand that during the course of the surgical procedure(s), unforeseen changes in my condition may arise which may necessitate a change in the care being provided to me. Should such an instance arise, I permit the anesthesiologist to provide treatment which he/she deems necessary for my safety and well being.
7. Dr. has fully explained to me the nature and the purpose of the procedure(s), the benefits, possible alternative methods of diagnosis or treatment, the risks involved, the possible complications, the
foreseeable consequences of the procedure(s), the likelihood of achieving treatment goals, and the possible results of non-treatment. I acknowledge that no guarantee or assurance has been made as to the results of the procedure.
Specifically, the risks identified to me include, but are not limited to, the following:
Procedure Consent Form
*015600.0609*
MR#
Acct#
Name
DOB
COMPLETE OR IMPRINT WITH ADDRESS-O-PLATE
FORM 0156-00 (REV. 06/09) PAGE 1 OF 2IM
PO
RT
AN
T: D
O N
OT
WR
ITE
IN
MA
RG
INS
1. I hereby authorize Dr.(s) to perform upon
(Patient Name) the following surgical and/or medical procedures: (State specific nature of the procedure(s) to be performed and describe its benefits
and likelihood of achieving treatment goals)
2. I authorize the following device(s) to be implanted during the above named procedure(s). (Describe type of device/implant):
3. I understand that the procedure(s) will be performed at Thomas Jefferson University Hospitals, Inc. by or under the supervision of the attending physician. He/She is authorized to utilize the services of such other health care professionals and trainees, including physicians and members of the house staff, as he/she deems necessary or advisable in the performance of the procedure(s) listed above. I understand that Thomas Jefferson University Hospital is an academic medical center and that students and trainees may be participating in my care, under appropriate supervision.
4. I understand that, during the course of the surgical procedure(s), unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedures than those set forth in Paragraph 1 above. I authorize and request that the above-named surgeon, his/her assistants, or his/her designees perform such surgical procedures as are necessary and desirable for my medical condition in the exercise of their professional judgment.
5. I acknowledge that the available anesthesia options have been explained to me along with their respective benefits and risks. I consent to the administration of the following type of anesthesia/sedation to be applied by or under the direction of my physician:
M Moderate Sedation (“Conscious Sedation”) M Local Anesthesia
6. If my physician determines that other anesthesia is necessary, a physician member of the Anesthesiology Department will obtain consent for any additional anesthesia required. I understand that during the course of the surgical procedure(s), unforeseen changes in my condition may arise which may necessitate a change in the care being provided to me. Should such an instance arise, I permit the anesthesiologist to provide treatment which he/she deems necessary for my safety and well being.
7. Dr. has fully explained to me the nature and the purpose of the procedure(s), the benefits, possible alternative methods of diagnosis or treatment, the risks involved, the possible complications, the
foreseeable consequences of the procedure(s), the likelihood of achieving treatment goals, and the possible results of non-treatment. I acknowledge that no guarantee or assurance has been made as to the results of the procedure.
Specifically, the risks identified to me include, but are not limited to, the following:
(REV. 06/15)
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October 2017
Prescription Slips
There are three approved prescription form layouts: single prescription (vertical or horizontal format) or a large prescription (vertical format only). The physician name(s), address and phone number should be preprinted on the form. The information in the bottom half of the form is required by law and cannot be altered. Department prescription forms (those without specific physician names listed) must carry the line “NOT VALID FOR SCHEDULE II
CONTROLLED SUBSTANCES.” • Medications cannot be preprinted. • Pads are printed in black ink only. • Nurse Practitioners (CRNP) must have a collaborating
physician’s name on the prescription form.• The physician’s license number must be listed with the
physician name. If not listed, the prescription form must carry the line “NOT VALID FOR SCHEDULE II CONTROLLED SUBSTANCES.”
To order, please visit Creative.Jefferson.edu.
Department/Practice Name
123 Street Avenue, Suite 456 Your City, PA 12345T 123-456-7890 F 123-456-7890 [email protected]
Indication ☐ Place Indication on Prescription Label
Refill Times Substitution Permissible Unless Indicated
Physician Signature
Ext/Beeper (where physician can be reached)
DEA #
Physician Name
MD-XXXXXX-L NPI-XXXXXXXXXX
NAME DOB
ADDRESS DATE
IN ORDER FOR A BRAND NAME PRODUCT
TO BE DISPENSED, THE PRESCRIBER MUST
HANDWRITE “BRAND NECESSARY” OR “BRAND
MEDICALLY NECESSARY” IN THE SPACE BELOW.