Medical Treatment Authorization & Release for Adults
Christ Fellowship Church
15600 New Hampshire Avenue Silver Spring, MD 20906 301-384-0281
To Whom It May Concern:
Should an emergency situation arise, in which I should become incapacitated & unable to communicate my wishes concerning medical treatment, I do hereby authorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of Christ Fellowship Church and/or its agents, may endanger my life, cause disfigurement, physical impairment, or undue discomfort if delayed. This includes surgery, anesthesia, and/or other procedures that the physician may deem necessary. This release and authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances. I also accept responsibility for any medical expenses as a result of any injury sustained.
Signed: ________________________________________________ Date: _________________
I give permission to Christ Fellowship Church, and/or its agents, and the Medical Personnel involved in an emergency situation in which I am incapacitated and can not speak for myself, permission to discuss any relevant medical treatment or condition, with the emergency contact person(s) listed below as well as my Family Physician.
Signed: ________________________________________________ Date: _________________
Person to Contact in case of an emergency: __________________________________________ Relationship to me: ___________________________ Contact Phone #s: Home _________________ Cell ________________Work ______________ Alternative Contact Person: _______________________________________________________ Relationship: _____________________________ Phone: _____________________________ Family Physician: _____________________________ Phone: __________________________ List any known allergies, illnesses, injuries or other pertinent comments:
Indicate all medications that you are presently taking, including directives:
Health Insurance Data: Company: ________________________________ Policy #: ______________________________ Group #: __________________________ Policy Holder’s Name: ___________________________ Copy of this form is valid as the original. Form - 202-B