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Emergency Medical Authorization

By Administrator, 06/10/22, 11:15PM PDT



(Authorized Agent of SBUWPC)


I/We, parent(s)/person(s) having legal custody/legal guardian of a minor, do hereby authorize medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by and is to be rendered by the general staff or medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician, dentist or at said hospital. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority to the aforesaid Agent to give specific consent to any; and all such diagnosis, treatment, or hospital care which a physician or dentist meeting the requirements of this authorization may in the exercise of his/her best judgment deem advisable. This authorization is given pursuant to the provisions of Sections 6910 and 6550 of the Family Code of California. This authorization shall remain effective until revoked in writing delivered to said agent(s).