If you are about to undergo a procedure, you can send this Health Authorization Letter to consent to the hospital and give an emergency contact to the hospital.
[Sender’s Name]
[City, State and Zip Code]
[Email Address]
[Date]
[Doctor’s Name]
[Hospital’s Name]
[City, State and Zip Code]
[Email Address]
Reference: Health Authorization to [Hospital’s Name]
To Whom It May Concern.
I [Patient’s Name] hereby authorize [Hospital’s Nae] to undertake [Procedure’s Name]. I have been informed by [Doctor’s Name] of the risks involved and that the chances of success are [Percentage]. Following this, I want to consent to the procedure.
The [Procedure] is scheduled for [Date] at [Time]. It will be significant towards my recovery from [Illness]. My emergency contact person is [Name], and their mobile number is [Number]. I have included the hospital records to effect this authorization.
Sincerely,
[Sender’s Signature]
[Sender’s Name]
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