TO WHOM IT MAY CONCERN:
_________________ (), age , address _________________, _________________, _________________ born , . of _________________, _________________, _________________, has my consent to administer any treatment (including but not limited to: x-ray, examination, anesthetic, medical, surgical or dental diagnosis and any hospital care) that are considered necessary in the best judgment of the attending medical or emergency personnel. This consent is given in prior to any such medical treatment, but is given to provide authority and power on the part of the in the exercise of their best judgment upon the advice of any such medical or emergency personnel.
If the injury or illness is life threatening or in need of emergency treatment, I authorize to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
Sworn to (or affirmed) and subscribed before me this _____ day of_____________, _______, by _________________
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
State of ____________
Commissioned Name of Notary Public
Personally Known OR Produced Identification
(Type of Identification Produced)