A medical authorization form is filled by a parent, guardian, employer or faculty head, allowing a medical practitioner to administer any necessary health procedures to a patient in the event of their unavailability or emergency.  When a patient is equipped with the medical authorization form, the guardian or the person responsible will not be required to participate directly in the medication process.

MEDICAL AUTHORIZATION FORM

Participant Information

Firs Name _____________ Middle Name ______________ Last Name_________________

Address ________________________ City _____________ Zip Code _______________

State _____________ Country _______________ Phone Number________________

Date of Birth ______________________________________________________________

MEDICAL AUTHORIZATION

I authorize the employer to accord the above named person any necessary medical attention including hospital and medical facility permissions on my behalf in case of an emergency.  The named person is covered by the health and insurance covers listed below which provide coverage for emergency situations:

Policy Number _________________________________________________________________________

Medical Information

Allergies: _____________________________________________________________________________________

______________________________________________________________________________________

Known medical conditions

__________________________________________________________________________________

____________________________________________________________________________________

__________________________________

Telephone contact in case of an emergency ______________________________________

Participant’s Signature _________________________ Date ________________________

Witness’s Signature __________________________ Date ________________________

Parent / Guardian’s signature (if under 18) ______________ Date__________________

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