紧急医疗授权

请输入或打印

如果我的孩子_______________________________________,出生日期 __________________,

如果我的孩子_______________________________________,出生日期 __________________,

如果我的孩子_______________________________________,出生日期 __________________,

        month/day/year

生病或涉及意外,我无法联系,我 授权以下医院或卫生保险公司给予紧急医疗 treatment required:


医院: ________________________________________________________________


地址: ________________________________________________________________

或者:


卫生服务提供者:_____________________________电话号码: ________________

                                                                 m.d./n.p。

                                                                              (Area Code)


地址: ________________________________________________________________


我给予________________________________________________ located at

                                                                             姓名 设施或看护人


________________________________________________,带走我的孩子(REN) treatment.


我承担医疗发生的任何必要费用的责任 治疗我的孩子(REN),未被以下内容涵盖:


健康保险公司: _________________________________________________


政策持有人姓名:___________________与儿童的关系(ren): ___________


政策编号:______________________医疗补助号码: _____________________


覆盖范围: _______________________________________________________________


儿童(仁)的已知过敏或健康状况:

是的 _____     No _____


如果是,请在此处解释: ______________________________________________________________

__________________________________________________________________________

__________________________________________________________________________


家庭地址: _________________________________________________________________

街道

市,州

邮政编码


区号/电话号码: _________________     _________________     _________________

首页                                                Business                                    Pager/Cell Phone


签名: _____________________________________________________________________


与孩子的关系(ren):___________________________________date: ________________

                                                                                                                   月日年