Medical Treatment Authorization by tracy12

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									           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

								
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