Authorization for medical and/or surgical treatment in the event of an emergency, due to an accident or illness



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AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT IN THE EVENT OF AN EMERGENCY, DUE TO AN ACCIDENT OR ILLNESS


Full name:

     

Address:

     

Telephone:

     

E-mail:

     

Person to be contacted abroad:

     

Relation:

     

Country:

     

Policy No.:

     

Insurance Company:

     

Mérida, Yucatán,       of       20     


International Office

Anahuac Mayab University

Carretera Mérida-Progreso Km. 15.5

Interior Km. 2 Carretera a Chablekal

Mérida, Yucatán, México.
I      

Born on/ (day)       (month)       (year)      




  1. Accept and authorize the hospitalization and treatment which will be carried out under the supervision of a qualified doctor.

  2. Accept and authorize the administration of anesthesia to my person which may be considered necessary or desirable according to the criteria of the doctor in attendance or the anesthetist.

  3. Accept and authorize the performance of any operation or procedure which may prove to be necessary or desirable according to the discernment of the doctor.

  4. Accept and authorize the administration of a blood transfusion or any other substance, or the administration of any medication, if deemed necessary. As the elaboration of these substances is not a function of the hospital, I exonerate said hospital of any responsibility.

Student’s signature (Patient)



Period of validity:      


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