Emergency Medical Authorization

*First Name

*Last Name

I hereby give consent, in the event I am incapacitated and unable to provide such consent and approval for a situation requiring emergency medical attention and action for the administration of any treatment or care deemed necessary, and the transfer of myself to any hospital reasonably accessible in an emergency situation.

The following information is being released by me in the event that the physician, dentist, healthcare professional, or hospital is unable to access my medical history:

*Do you have any allergies?

If yes, please list:

*Do you take any medications?

If yes, please list:

*Do you have any physical limitations?

If yes, please list:

*Other critical information (blood type, health conditions,etc.)

*Digital Signature

*Date

Submit