Authorization For Treatment Template Page 2

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Witness
Relationship to Patient
– OVER –
Record of Attempts To Inform Authorized Representative of Admission/Need for Signature
Date: _________ Time: ________ Date: _________ Time: ________ Date: _________ Time: _________
Auth. Repres. ________________ Auth. Repres. ________________ Auth. Repres. __________________
INFORMED
INFORMED
INFORMED
UNABLE TO REACH
UNABLE TO REACH
UNABLE TO REACH
MESSAGE LEFT
MESSAGE LEFT
MESSAGE LEFT
SIGNED: ____________________ SIGNED: ____________________ SIGNED: ____________________
Emergency Room
Floor Nurse
Case Coordinator

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