MEDICAL AUTHORIZATION FORM

Patient Information

Full Name:

Date of Birth:

Address:

Authorized Person

I authorize the following person to make medical decisions on my behalf:

Name:

Relationship:

Phone:

Scope of Authorization

☐ Emergency medical treatment only

☐ Routine medical care

☐ Access to medical records

☐ Discuss treatment with healthcare providers

☐ Other:

Duration

Start Date:

End Date:

Medical Information

Allergies:

Current Medications:

Medical Conditions:

SIGNATURE

I understand that this authorization allows the person named above to make medical decisions on my behalf.

Patient Signature: ______________________________ Date: ______________

Print Name:

Witness Signature: ______________________________ Date: ______________

Witness Name: