Emergency Authorization Form
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 of the agency, I authorize Miles of Smiles Foundation's Equine Therapy Program to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) below is/are unable to be reached.