AUTHORIZATION FOR MEDICAL TREATMENT. In the event that I cannot be reached to make arrangements for medical treatment, I authorize YMCA Staff to administer first aid/or transport to the nearest hospital or emergency care facility. Name of Licensed Physician or Emergency-Care Facility: _________________________________________________________________________ Street Address: _____________________________________________________ City: _______________________ State: _______ Zip: ____________________ Phone Number:______________________________________________________ I certify that has been examined by a licensed physician in the past 12 months, is able to participate in the YMCA Day Camp Program. The Health History is correct as far as I know, and the person herein described has permission to engage in all prescribed activities and fieldtrips, except as noted by the examining physician and me.
AUTHORIZATION FOR MEDICAL TREATMENT. “If an accident happens and if I cannot be reasonably reached, I give permission for emergency medical treatment and promise to cover medical costs if treatment is needed.”
AUTHORIZATION FOR MEDICAL TREATMENT. In the event of an emergency, I do hereby authorize any and all medical treatment to be provided to me including, without limitation, emergency treatment and transportation, X-ray, anesthetic, dental, medical or surgical diagnosis or treatment by any licensed physician or dentist, as applicable, and any hospital services that might be rendered on my behalf. I hereby assume all responsibility for the expenses associated with the performance of such services. This permission may be revoked at any time by providing notification in writing to the Admission’s Office.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize my physician(s) and his/her designee(s), other individuals with privileges to provide services at BCDI, and their employees to provide medical services to me, including diagnostic tests and therapeutic procedures necessary for the diagnosis and treatment of my illness or condition. Treatment means the provision, coordination or management of your health care, including consultations between health care providers relating to your care and referrals for health care from one health care provider to another. I further authorize medical care, testing, and treatment as necessary in emergency situations to preserve my life and the health of persons involved in my care without first obtaining consent from me or my family. I understand that BCDI may be a teaching institution, providing clinical training opportunities for medical, nursing, and allied health student and residents. I consent to such students and residents being involved in my care and treatment and understand that they are not employees of my physician or BCDI.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Guardian Pharmacy, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. In recognition of the risks, which I am assuming by voluntarily participating in these activities, I hereby give TAKE FLIGHT, its agents and employees permission to treat me and to authorize medical treatment of me in the case of an emergency or accident.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Guardian Pharmacy of Michigan, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. I hereby authorize medical treatment for the minor child for whom I am guardian or otherwise responsible (who is listed below), at my cost, if the need arises, however I acknowledge that the Released Parties shall have no duty, obligation or liability arising out of the provision of, or failure to provide or administer medical care or treatment.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Xxxxxx’x Extended Care Pharmacy, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. I hereby authorize any medical treatment deemed necessary in the event of any injury while participating in the activity. I either have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my behalf.
