Authorization of Emergency Medical Treatment
In the event emergency medical aid/treatment is required, due to illness or injury, during the process of receiving services or while being on the property, by signing this form, I authorize Rockin' Horse Farm and Horse Connections to: 1. Secure and retain medical treatment and transportation, if needed 2. Release personal records upon request to the authorized individual or agency involved in the emergency medical treatment.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact
*
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Preferred Medical Facility
*
Primary Physician Name
Health Insurance Company
Policy Number
Primary Insurance Holder Name and Date of Birth
Signature of participant or authorized adult if participant is a minor
*
Date
*
-
Month
-
Day
Year
Date
Phone Number of signee
*
Please enter a valid phone number.
Submit
Should be Empty: