Cantr

You are here: Emergency Medical Treatment
Authorization for Emergency Medical Treatment
  1. I am a (*)
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  2. First Name(*)
    Please enter your first name.
  3. Middle Initial
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  4. Last Name(*)
    Please enter your last name.
  5. Date of Birth(*)
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    (MM/DD/YYY)
  6. E-mail address(*)
    Please enter a valid email address.
  7. Confirm e-mail address(*)
    Please confirm your e-mail address.
  8. Phone(*)
    Please enter a phone number.
  9. Address(*)
    Please enter your address.
  10. City(*)
    Please enter the state where you live.
  11. State(*)
    Please enter the state where you live.
  12. Zip Code(*)
    Please enter your zip code.
  13. Physician's Name(*)
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  14. Physician's Phone(*)
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  15. Medical Facility(*)
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  16. Health Insurance Company
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  17. Group Number
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  18. Subscriber Number
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  19. Allergies(*)
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    (If none, input "none")
  20. Current Medications(*)
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    (If none, input "none")
  21. Name of Emergency Contact(*)
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  22. Relationship to you(*)
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  23. Phone for emergency contact(*)
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  24. Name of Emergency Contact(*)
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  25. Relationship to you(*)
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  26. Phone for emergency contact(*)
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  27. Name of Emergency Contact(*)
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  28. Relationship to you(*)
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  29. Phone for emergency contact(*)
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  31. 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 CAN-TR to: 1) Secure and retain medical treatment and transportation if needed. 2) Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
  32. CONSENT PLAN
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  33. Digital Signature (Full Name)
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    If under the age of 18, the parent/legal guardian must sign. This is a digital signature. By typing your name, you are signing this document.
  34. NON-CONSENT PLAN
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  35. In the event emergency treatment/aid is required, I wish the following procdures to take place
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  36. Digital Signature (Full Name)
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    If under the age of 18, the parent/legal guardian must sign. This is a digital signature. By typing your name, you are signing this document.
  37. Date(*)
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  38. WARNING: Under NC Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. -Chapter 99E of the NC General statutes.
  39. Please type the characters you see here.
    Please type the characters you see here.
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  40. Submit Form