Request and Authorization for Transfer and Emergency Care

Patient Name: __________________________________________________ Date: ________

I, the undersigned, request that Dr. __________________________________________________ transfer __________________________________________________ to ____________________.

I hereby authorize Dr. __________________________________________________ or whom he may designate to perform whatever emergency treatment is required in route and on arrival at ____________________.

I also consent to the administration of such medications as necessary. I hereby certify that I have read, and been verbally informed, and fully understand the reasons for transfer, and grant authorization for transfer and emergency care. The reason for transfer is that a higher level of care is necessary and cannot be provided in this facility, and the dangers of transfer are less than not seeking higher levels of care. I have been informed of the hospital's obligations under the relevant law and the risk of such transfer, if any, as well as possible alternative modes of treatment which were explained to me by Dr. __________________________________________________.

I also certify that no guarantee or assurance has been made as to the release of any or all information to the receiving hospital that is necessary for an appropriate transfer.

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Signature (Patient or nearest relative)

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Relationship (if other than Patient)

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Date

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Witness Signature and Position or Title

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Date