Release forms - 2 of 4

RIDER'S AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT 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 PAL-O-MINE EQUESTRIAN to:
Secure and retain medical treatment and transportation, if needed. Release client records upon request to the authorized individual or agency involved in the emergency medical treatment.
Client's Name
Phone:
Street Address:
City:
State & Zip:
In the event I cannot be reached,
Contact 1:
Phone:
Contact 2:
Phone:
Consent Plan
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 below is unable to be reached.
Consent Signature:	Client, Parent or Guardian
Date:
Print Name:
Phone:
Street Address:
City:
State & Zip:
Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
Non-Consent Signature:	Client, Parent or Guardian
Date:
Print Name:
Phone:
Street Address:
City:
State & Zip:
A Copy Of The Completed Medical History Should Be Attached To This Form

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Pal-O-Mine Equestrian, Inc. • 829 Old Nichols Road • Islandia, NY 11749