Section 1

Full Name*

Email address*

Address*

Phone Numbers

Home

Work

Section 2

Are you a member of The Mother Church?*
YesNo

Are you a member of a branch church?*
YesNo

Have you had class instruction?*
YesNo

Have you ever been a Journal-listed CS practitioner or nurse?*
YesNo

It is Morning Light’s policy for patients receiving Christian Science nursing care to have daily treatment from a Journal-listed Christian Science practitioner and for the Christian Sciences nurses to be in contact with the practitioner. Some exceptions may apply

Section 3

Name of Journal-listed CS practitioner on case*

Phone #*

Email address

City and State of Journal listing*

Alternate Christian Science practitioner, if regular practitioner cannot be reached:

Name*

Phone #*

Section 4

Name of nearest relative*

Relation*
FatherMotherSonDaughterBrotherSisterHusbandWifeGrandfatherGrandmotherCousinUncleAuntNephewNiece

Relative's Address*

Relative's Phone Numbers

Home

Work

Relative's Email address

Section 5 - Health Care power of attorney or legal guardian

please provide copy of health care directive

POA Name*

POA Address*

POA's Phone Numbers

Home

Work

My Health Care power of attorney and/or the following people have permission to participate in discussions about my
health care
YesNo

Section 6 - Person to whom bills should be sent

IMPORTANT NOTE: Morning Light Christian Science Nursing Service is not eligible for either the Medicare or Medicaid program. Insurance coverage is dependent upon individual policies and is the responsibility of the patient and/or family.

Name*

Relation*
FatherMotherSonDaughterBrotherSisterHusbandWifeGrandfatherGrandmotherCousinUncleAuntNephewNiece

Billing Address*

Relative's Phone Numbers

Telephone

Work

Billing Email address

Please indicate your financial arrangements for paying bills*
PersonalFamily FinancesPrivate Insurance

Please read carefully the following declaration so that you understand the conditions for care provided by Morning Light.

• I am an adherent of Christian Science and rely wholly upon God for healing.

• I have read and agree to the STATEMENT OF UNDERSTANDING concerning Christian Science nursing services provided by Morning Light Christian Science Nursing Service.

• I understand it is Morning Light’s policy that an individual receiving Christian Science nursing care has daily treatment from a Journal-listed Christian Science practitioner.

• In the event that the Christian Science practitioners of my choice cannot be reached in an emergency, I hereby authorize Morning Light Christian Science Nursing Service to call another Journal-listed practitioner to treat me until such time as my regular practitioner is again available.

• I agree to comply promptly if a change in my care plan is needed in order that I may receive proper care.

• I understand a statement of daily charges will be presented and are due as billed. Questions and financial arrangements should be directed to the Morning Light administrator.

• I understand that Morning Light Christian Science Nursing Service is not responsible for my valuables or personal property

STATEMENT OF UNDERSTANDING

I understand that the ministry of Morning Light Christian Science Nursing Service includes providing Christian Science nursing services consistent with the theology of Christian Science, and therefore I understand and expect that this does not include medical involvement.

The care of the Christian Science nurse includes:

• Accepting a case with the expectancy of complete and immediate healing;

• Giving care that is consistent with the theology and ethics of Christian Science;

• Loving reassurance of God's tender care, ever-presence, and omnipotence; faithfully and consistently acknowledging man's spiritual perfection;

• Christian encouragement of an individual's expression of normal activity and natural vitality;

Reading to or with an individual from the Bible, Science and Health with Key to the Scriptures and other writings by Mary Baker Eddy; also, additional literature published by The Christian Science Publishing Society;

• Communication: maintaining an ethical, moral, and loving manner in all communications with the patient, family, friends, Christian Science practitioner, and others; observing ethical and legal requirements with regard to private information about the patient;

• Surroundings: maintaining an atmosphere that is conducive to spiritual healing and supportive of harmonious care;

• Personal care and bathing: assisting with all necessary care to meet the needs of cleanliness and comfort;

• Mobility: assisting with mobility including assisting with standing, walking, moving, and settling with or without mobility aids or comfort items;

• Nourishment: preparing and modifying food; assisting with feeding; giving appropriate encouragement to eat;

• Cleansing/bandaging: cleansing, covering and bandaging, to provide for cleanliness, protection, support, and comfort;

• Instructing the patient or others in providing care for meeting individual needs;

• Being obedient to the laws of the land.

The care of the Christian Science nurse does not include:

• Making a medical diagnosis or prognosis;

• Assuming responsibility for making health care decisions for the patient;

• Administering medication, drugs or using medicated, herbal, or vitamin-based products and remedies;

• Using and administering medically oriented techniques or technology;

• Manipulation, massage, physical therapy;

• Intravenous or force-feeding;

• Assuming responsibility for a patient's financial or household business transactions;

• Intruding on the private relationship between the patient and the Christian Science practitioner, or between the patient and his or her family;

• Giving personal advice and counsel.

Fundamental to the ministry of a Christian Science nurse is an active, prayerful confirmation of man's innate spirituality and responsiveness to God's harmonious government. This spiritual witnessing undergirds each aspect of the care a Christian Science nurse renders.

Your submission of this form indicates your understanding of these statements and your desire to receive the care described above:

Please prove you are human by selecting the heart.