Medical Consent Draft

Welcome to the draft of your customized document, feel free to make changes by clicking the edit button and when you are satisfied you can purchase the document for $11 USD by clicking the purchase button below.

Once you purchase your document you can download and edit it as many times as you like. Documents are available in all popular word processing formats so you are able to modify and customize it as much as you like.


Edit Document Purchase Document

MEDICAL CONSENT

 
 
TO WHOM IT MAY CONCERN:
 

     
    _________________ (), age , address _________________, _________________, _________________ born , .
     
     
  1. 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.
     
     
  2. 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.
     
     

     
    _________________
    _________________,
    _________________
     
    Phone Numbers:
     
    Home: _________________
    Work: _________________
    Cell: _________________
     
     
    Signature: _____________________________________________
     
     
    (OPTIONAL)
    CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
    Sworn to (or affirmed) and subscribed before me this _____ day of_____________, _______, by _________________
     
     
    _______________________________
    Notary Public
     
    State of ____________
     
     
    _______________________________
    Commissioned Name of Notary Public
     
    Personally Known OR Produced Identification
     
    ________________________________ (Type of Identification Produced)
     
Edit Document

Copyright © 2005-2017 SMARTFORMZ. Use of the Smartformz website is subject to our: Privacy Policy and Disclaimer