In the event of an emergency, illness or injury affecting me, I, the undersigned, hereby authorize immediate hospitalization and treatment recommended by and carried out under the supervision of a qualified physician or other medical personnel, including but not limited to administering an anesthetic and performing necessary surgery.
Further, I have a companion who is going on the trip, and may make emergency medical decisions for me, including, but not limited to decisions related to transferring me to alternate medical facilities outside of the United States or to the United States for additional medical care.
I am covered by health and accident insurance that provides coverage while traveling out of the United States under the following company and policy:
Submitting this form implies that your consent of this document.
17 Main Street, #12
Lee, MA 01238
(336) 416-2390 - Ramelle
(413) 717-5459 - Michael