This Printable Business Form Template belongs to these categories: medical
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123 Marygold St.
Anytown, CA 95928
(555) 555-1212
November 1, 2008
Attention [name of doctor, hospital or treatment center]:
I, Jennifer Jensen, authorize my daughter, Holli Hollister, of 123 Marigold St., to authorize any necessary emergency medical care on my behalf in the
event that I am not able to do so.
This authorization is valid from November 1 through December 31 of 2008.
Sincerely,
Jennifer Jensen
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