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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