Flowers Hospital, located in Fort Myers, Florida, is one of the largest medical centers in the region. The hospital has a wide variety of services available to patients, including a 24/7 emergency room and a cancer center. In addition, Flowers Hospital offers medical imaging services, such as x-rays and MRIs. If you need to have surgery or other procedures done at Flowers Hospital, you will likely be asked to complete a form known as the "Flowers Admission Agreement." This form gives the hospital consent to treat you and authorizes your insurance company to pay for your care. Completing this form is important - if you don't sign it, you may not be able to receive treatment at Flowers Hospital. So make sure to read through it carefully and ask any questions you have before signing it.
| Question | Answer |
|---|---|
| Form Name | Flowers Hospital Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | ST Application Flowers Hospital flowers hospital form |
FLOWERS HOSPITAL
4370 West Main Street
Dothan, AL 36305
Surgical Technologist Program Application
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Class Start Date Applied For: ___September_____________ |
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Social Security # _____________________ |
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Current Address: |
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Contact Phone: ( |
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If you have lived at the above address for less than 12 months, list your previous address: |
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Name of husband or wife |
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Where he/she is employed___________________ |
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Are you at least 18 years old? Yes No (Check one)
Have you been convicted of any criminal offense (a misdemeanor or felony) other than traffic violations? Yes No
Have you been confined following a conviction for any criminal offense?
Yes No
Are you presently charged with any violation of the law other than traffic violations? Yes No
Have you ever been sanctioned by any governmental payor (such as Medicare, Medicaid, or Champus)? Yes No
If your response to any of the preceding four questions was "yes", provide the date, place and nature of each such action, conviction or pending charge on a separate sheet. (The existence of a conviction or pending charge will not necessarily preclude your acceptance into the program. The nature of the crime and its relationship to the health care program applied for, the degree of rehabilitation that has occurred and the time elapsed since the time or release from confinement will be considered.)
Have you ever been employed at Flowers Hospital, Home Care Services, Westside Terrace, Breathing Care Associates or any other Flowers owned facility before (under current or prior ownership)? Yes No
Have you ever been employed by another CHS facility? Yes No
If yes, give position and dates you worked: _____________________________________________________
List any relatives working for us and show their relationship: ________________________________________
Special skills you possess (include any special skills from military service: _____________________________
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Long range occupational goals: ______________________________________________________________
Education |
Did you finish? |
Name of school and location |
Grad. Date Avg Grades |
High School
College
School of Nursing
Special School or Training
Professional Licenses and Certifications:
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Have any disciplinary actions or investigations been initiated or are any pending against you by any state licensure board? Yes No
Has your license to practice in any state ever been challenged, denied, limited, suspended, revoked, voluntarily or involuntarily relinquished? Yes No
If the answer to either of the above questions is "yes" please provide full explanation of the details on a separate sheet and attach.
Employment History
List all previous employers for whom you have worked in the last ten years. (List in order, last or present employer first. Attach extra sheet if necessary.) Please indicate full name used at time of hire and at time of termination at each place of employment.
EMPLOYER NAME:
Employer Address:
Phone:
Name used during employment: |
Date (From - To): |
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Reason for Leaving:
State position held and describe work you did:
EMPLOYER NAME:
Employer Address:
Phone:
Name used during employment: |
Date (From - To): |
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Reason for Leaving:
State position held and describe work you did:
EMPLOYER NAME:
Employer Address:
Phone:
Name used during employment: |
Date (From - To): |
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Reason for Leaving:
State position held and describe work you did:
EMPLOYER NAME:
Employer Address:
Phone:
Name used during employment: |
Date (From - To): |
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Reason for Leaving:
State position held and describe work you did:
Describe any lapses: _______________________________________________________________________
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Describe why you are interested in becoming a Surgical Technologist. Describe how you learned about the program and what you believe the job involves:
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Personal References (not former |
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employers or relatives) |
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Name and Occupation |
Address |
Phone Number |
I understand and agree that:
1.The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of my acceptance in the Flowers Hospital Surgical Technologist Program, or if accepted, termination from the program.
2.I authorize and request that all of my present and former employers and those individuals I have listed as business references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any liability for damages arising from furnishing the requested information.
3.I understand that as a condition of acceptance in the Flowers Hospital Surgical Technologist Program, I will be required to undergo and successfully pass a screening for drugs. I also understand and agree that, if accepted, I may be required to submit to an alcohol or drug screening at any time at the discretion of the facility. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to the facility.
4.I hereby authorize this facility to investigate my employment and personal history, including an inquiry concerning information on my criminal, credit and driving history, if appropriate. I understand that the facility will consider material contained in my criminal history records and other records solely for the purpose of determining my suitability for the position(s) for which I have applied. I do not authorize release of this information for any purpose beyond this employment decision. I am aware that if I am denied employment based on a report by a consumer reporting agency, the facility will furnish the name and address of such agency upon my written request.
5.I hereby authorize this facility to verify with the appropriate educational institution and/or professional licensing agency the educational history which I have provided herein or in a resume or other document including the date(s) attended; course(s) taken; and degrees, certifications, or licenses received or issued and their current status.
6.In consideration of my acceptance into the Flowers Hospital Surgical Technologist Program, I agree to comply with the policies, rules, regulations, and procedures of the facility and understand that my acceptance be terminated with or without cause or notice at any time, at the option of either the company or myself. I further understand that no manager or representative of this facility other than the President, General Counsel, or Group Vice President of Community Health Systems, Inc. has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and by one of the individuals designated above.
I UNDERSTAND AND AGREE THAT IF I AM ACCEPTED INTO THE FLOWERS HOSPITAL SURGICAL TECHNOLOGIST PROGRAM, THIS WILL NOT CONSTITUTE A JOB OFFER FROM FLOWERS HOSPITAL. I UNDERSTAND THAT IF I AM INTERESTED IN EMPLOYMENT WITH FLOWERS HOSPITAL, I MUST SUBMIT AN EMPLOYMENT APPLICATION AND WILL BE CONSIDERED FOR EMPLOYMENT ALONG WITH OTHER APPLICANTS.
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I,_____________________________, hereby certify that I am not currently excluded, debarred or otherwise
ineligible to participate in the Federal health care programs or in Federal procurement or
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Signature |
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A copy of your high school diploma or GED should accompany this application.
S:\HUM_RES\WORD\FORMS\SURGTECH.DOC 4/21/2008