Consent for Emergency Treatment. I authorize the University of Wisconsin – Green Bay and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION.
Appears in 9 contracts
Samples: Agreement for Assumption, Agreement for Assumption, Agreement for Assumption
Consent for Emergency Treatment. I authorize the University of Wisconsin – Wisconsin-Green Bay and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION.agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date:
Appears in 2 contracts
Samples: www.uwgb.edu, www.uwgb.edu
Consent for Emergency Treatment. I authorize the University of Wisconsin – Green Bay and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION.. Signature: Date:
Appears in 1 contract
Samples: Agreement for Assumption
Consent for Emergency Treatment. I authorize the University of Wisconsin – Green Bay and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION.. Signature: Date: Signature of Parent or Guardian
Appears in 1 contract
Samples: www.uwgb.edu
Consent for Emergency Treatment. I authorize the University of Wisconsin – Wisconsin-Green Bay and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION.agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature of Parent or Guardian __________________________________Date:______________________
Appears in 1 contract
Samples: www.uwgb.edu