Authorization for Emergency Medical Treatment

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
In the event of an emergency, I authorize TRIANGLE to provide or arrange for emergency medical treatment for:*
while pending further medical services.

I understand that TRIANGLE staff will make every effort to contact me as soon as possible after the incident.

I understand that I am free to withdraw consent at any time. I give my consent voluntarily, without threat of punishment or promise of reward. I have discussed this release with the person obtaining my consent and have had my questions answered. This consent expires after one year.
Individual's Signature*

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Date*

MonthDayYear
Date
Signature and Position of Person Obtaining Consent

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Date

MonthDayYear
Date
Legal Guardian's Signature*

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Date*

MonthDayYear
Date

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AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT