Patient authorization letter

Patient authorization power of attorney

If the delegatee has not made any rights and interests contrary to the laws of the country, the delegatee shall not be able to use any reason for the exercise of the power of the delegatee to backtrack. In today's social life, dealing with affairs we need to use the power of attorney, I believe that writing a power of attorney is a headache for many people, the following is a patient authorization power of attorney that I help you to organize, for reference only, we take a look at it.

Patient authorization power of attorney 1

The client (the patient himself) situation:

Name: xxxxxxxxxx Gender: xx Age: xx Phone: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Residential address: I hereby authorize xxxxxx

as my agent to: (1) understand my condition on my behalf; (2) exercise my right of informed consent during my hospitalization and perform the corresponding signing procedures on my behalf, including the following cases:

when anesthesia, surgery and invasive examination and treatment are performed on me;

when expensive drugs and consumables are used, or when expensive examinations are performed;

when transfusion of blood and blood products are performed on me due to my medical condition. When transfusing blood and blood products;

When I am temporarily incapable of giving informed consent but my condition requires appropriate treatment.

Signature of the patient: Month of the year

Signature of the trustee: Month of the year

Patient's authorization2

Principal: ___________

Trustee: ___________

I was admitted to the hospital on ___________ on ___________. Admitted to the hospital. In order to ensure that the diagnostic and therapeutic activities carried out by the hospital on me can be carried out smoothly, and at the same time, in order to realize my right of informed consent during this hospitalization, I solemnly entrust as my agent to authorize him/her to:

1. Understand my condition on behalf of me;

2. Exercise the right of informed consent during the period of hospitalization on behalf of me, and perform the corresponding signing formalities, which include the following cases:

① anesthesia, surgery, as well as invasive examination, treatment;

② the use of expensive drugs, consumables or expensive tests;

③ I belong to the public health care, rural cooperative medical care, social security patients, etc., the cost of diagnosis and treatment of diseases beyond the scope of the reimbursement of the use of specific medicines or to take specific medical measures;

④ because of the condition of the need for the person (4) When I need transfusion of blood and blood products and when I need experimental treatment;

(5) When I do not have the ability to give informed consent for the time being, but I need urgent treatment because of my critical condition

Principal: ___________

Trustee: ___________

Date: ___________

Patient's Authorization Power of Attorney 3

Principal (patient himself): Name Gender Age Bed No. Hospitalization No. Address

Phone No. I.D. No.

Appointee: Name Gender Age Work Unit Relationship with Patient Address

Phone No. I.D. No.

I was admitted to the hospital on January 1, 2012. In order to ensure that the hospital's diagnostic and therapeutic activities for me can be carried out smoothly, at the same time, in order to realize my right to informed consent during the hospitalization, I solemnly entrust as my agent, authorized to:

1. on behalf of the understanding of my condition;

2. on behalf of the exercise of hospitalization during the right to informed consent, and the implementation of the corresponding signing formalities, including the following cases:

1. ① anesthesia, surgery, as well as invasive examination and treatment of me; ② the use of expensive drugs, consumables or expensive tests;

④ because of the condition of the need for blood transfusion of blood and blood products and the use of experimental blood products for me. (4) When the condition of the patient requires the transfusion of blood and blood products and the experimental treatment of the patient; (5) When the patient does not have the ability to give informed consent for the time being, but the patient's condition is critical and requires urgent treatment

Signature of the commissioner: (Handprint) Month, year

Patient Authorization Letter 4

Patient's name___ ____ Sex _____ Age ____ Subject___ ____ Case No. ____ I am a social security patient, and I am not a social security patient, and I am not a social security patient. ____ Case No. ___________ I was admitted to the ___________ hospital on January, 2012 due to illness. In accordance with the relevant legal provisions, I appoint ___________ as my agent to act on my behalf in exercising my right to make medical informed consent choice decisions during my current hospitalization. The reason I entrust this person is __________________________________________________________. Principal (patient himself): Gender Age

Valid ID number: Residential address:

Trustee: Gender Age Telephone number: Valid ID number: Residential address: Relationship with the patient: □spouse □children □parents □other close-relatives □colleagues □friends

Trustee's authority is to: on behalf of the understanding of the patient's own medical condition, medical treatment measures, medical risks; on behalf of exercising the right to make informed consent decisions on health care, and to fulfill the right to make informed consent choices on behalf of me, as well as to exercise my right to make informed consent decisions on health care. The trustee's authority is to understand the patient's condition, medical measures and medical risks on behalf of the patient; to exercise the right to choose and decide on behalf of the patient to give informed consent to medical treatment; and to fulfill the corresponding signing procedures, including the following cases:

□ when anesthesia, surgery and special examination and treatment are performed on the patient;

□ when the patient's condition changes and needs to be resuscitated;

□ when an unforeseen circumstance occurs in the course of resuscitation or surgery that requires a change of the scheduled operation mode and surgical plan, emergency blood transfusion, removal of In case of emergency blood transfusion, removal of organs or larger tissues, or ligation of important blood vessels during rescue or surgery;

□ In case of use of expensive medicines, consumables or special examinations with high prices;

□ In case of use of specific medicines or adoption of specific medical measures for the purpose of diagnosis and treatment of illnesses beyond the scope of the reimbursement for patients who belong to different types of insurances such as publicly-funded medical care, comprehensive social medical care insurance for major illnesses, and the new type of rural cooperative medical care, etc.

□ When the patient needs to be transfused with blood and blood products and to have his/her own blood transfused. transfusion of blood and blood products or experimental treatment of the patient;

□ implantation of artificial organs or other medical biological materials;

□ refusal of other family members of the patient to use the medication and treatment measures for the patient's condition.

□ Surgical treatment and other circumstances encountered in the diagnosis and treatment: _____________________.

Patient's signature: ___________

Signature time: Month, year, hour, minute, place of signature:

I confirm and accept that the patient _________ authorizes me to exercise the right of medical informed consent to make decisions on behalf of him/her during the period of hospitalization, including understanding the patient's medical condition, medical treatment measures, medical risks, and other above mentioned contents on behalf of him/her; On behalf of the exercise of medical informed consent to choose the right to decide, and fulfill the corresponding signature procedures.

Signature of the trustee: ______ ___ID No.: _______________________________ Signature time: Month Day, hour and minute Signature place:

Note: It is recommended to use a duplicate, a copy of which is handed over to the patient to save, and the other to be kept in the medical record.

Patient Authorization Form 5

]Name Gender Age Ward Bed No. Hospitalization No.

Client (patient) Name: Valid ID number: Document Category: Mouth ID card Mouth Passport Mouth Officer's license Mouth Other

Name of the appointee: Gender Age Contact Tel:

Valid ID number: Document Category: Mouth ID card Mouth Passport Mouth Officer's license Mouth Other

The patient is the only person who can sign the form. Other

Relationship with the patient: mouth spouse mouth children mouth parents mouth other close - relatives mouth colleagues mouth friends mouth other:

Declaration of the commissioner:

I was hospitalized in the year on the date of hospitalization due to illness. During my hospitalization, I fully entrusted as my agent, on behalf of me to the medical services provided by the doctor, exercise informed consent and choice of treatment plan and other rights, and on behalf of me to sign the relevant medical documents. The signature of the authorized person shall be deemed to be my. The signature of the delegate is regarded as my signature.

I make the above authorization to the delegate on a completely voluntary basis, the delegate to engage in the delegated activities arising from the

consequences, fully borne by me.

Signature or handprint of the delegator (patient): Date: January

Signature of the delegatee: Date: January

Note: The delegator refers to the patient with full civil behavior, the guardian of the patient who does not have full capacity for civil behavior. This power of attorney

need to be saved in the medical record at the same time with the relevant consent form; a copy of the valid identity certificate is pasted on the reverse side of this power of attorney

Patient Power of Attorney 6

Patient's name Gender _____ Age Section Case No.

I was admitted to the North Hospital on January 1 due to illness. In accordance with the relevant legal provisions, I entrust ___________ as my agent to act on my behalf to exercise my right to make medical informed consent choice decisions during my current hospitalization.

I appoint this person for _______ __________ _______ reasons. Delegate (patient himself): Name Gender Age

Valid document number (ID card):

Trustee: Gender Age Telephone number:

Valid document (ID card) number:

Relationship with the patient: □ Spouse □ Child □ Parent □ Other close - relatives □ Colleague □ Friend

The authority of the trustee is to: on behalf of understanding the patient's The trustee's authority is to understand the patient's condition, medical measures and medical risks, to exercise the right to choose medical informed consent on behalf of the patient, and to fulfill the corresponding signing procedures, including the following cases:

□ When anesthesia, surgery, or special examination or treatment is performed on the patient;

□ When there is a change in the condition of the patient that requires resuscitation;

□ When there is an accident in the course of resuscitation or operation □ When there is a need to change the scheduled operation and surgical plan, emergency blood transfusion, removal of organs or larger tissues, or ligation of important blood vessels;

□ When expensive medicines and consumables are used, or when special examinations with high prices are conducted;

□ When patients belonging to different types of insurances such as publicly-funded medical care, social medical insurance for the overall management of major illnesses, or the new type of rural cooperative medical care, etc., are given specific medicines or take specific medical measures for the purpose of diagnosis and treatment of illnesses that are outside of the scope of the prescribed reimbursement. When using specific drugs or adopting specific medical measures for the diagnosis and treatment of diseases beyond the scope of reimbursement;

□ When transfusion of blood and blood products is required for the patient and when experimental treatments are adopted;

□ When implantation of artificial organs or other medical biological materials is required;

□ When other family members of the patient refuse to adopt the diagnostic and treatment medicines and diagnostic and treatment measures given to the patient's condition.

□ Surgical treatment and other circumstances encountered in the diagnosis and treatment: ________.

Signature of the patient:

Signature time:

Signature place:

I confirm and accept that the patient, including on behalf of the understanding of the patient's condition, medical treatment, medical risks and all the above; on behalf of the exercise of medical informed consent to choose the right to decide, and to fulfill the corresponding signing procedures.

Signature of the trustee:

Signature Time: Month Day Hour Signature Place:

Note: It is recommended to use a duplicate, a copy of which is submitted to the patient for retention, and the other to be kept in the medical record.

Patient authorization letter 7

Patient name _______ gender _______ age _______ department ______ case number ___________ In accordance with the relevant provisions of the law, I entrusted as my agent, during my current hospitalization, on behalf of me to exercise the right of medical informed consent to choose decisions.

Client (the patient himself): gender age

Valid ID number: Address: Trustee: gender age Telephone: Valid ID number: Address: Relationship with the patient: □ Spouse □ Children □ Parents □ Other close relatives □ Colleagues □ Friends

Trustee's authority to: on behalf of the understanding of the patient's own condition, medical treatment, medical risks; on behalf of exercising the right of informed consent to choose decisions on medical care, and fulfill the right of informed consent to choose. The trustee's authority is to understand the patient's condition, medical measures and medical risks on behalf of the patient; to exercise the right of informed consent and decision-making on behalf of the patient; and to fulfill the corresponding signature procedures, including the following cases:

□ When anesthesia, surgery and special examination and treatment are performed on the patient;

□ When there is a change in the condition of the patient that requires resuscitation;

□ When there is an unforeseen circumstance that requires a change of the scheduled operation and surgical plan in the course of the resuscitation or surgery, emergency blood transfusion, removal of □ When using expensive drugs, consumables or conducting special examinations with high price;

□ When patients belonging to different types of insurances, such as public medical care, social medical insurance for major illnesses, and the new type of rural cooperative medical care, use specific drugs or take specific medical measures for the purpose of diagnosis and treatment of illnesses that are beyond the scope of the stipulated reimbursement;

□ When the patient needs to be transfused with blood and the patient's own blood or when the patient needs to be treated by a medical doctor. transfusion of blood and blood products or experimental treatment of the patient;

□ implantation of artificial organs or other medical biological materials;

□ refusal of other family members of the patient to use the medication and treatment measures for the patient's condition.

□ Surgical treatment and other circumstances encountered in the diagnosis and treatment: _____________________.

Patient's signature: ___________

Signature time: year and month ____ hour ____ minute

Signature place:

Patient's authorization letter 8

Name of the client (patient): _____________ Valid ID number: ________________________ Type of document: □ ID card □ passport □ officer's license □ other

Name of the delegatee: ____________ Gender: ______ Age: ________ Contact number: ____________ Valid ID number: ______________________________________________________ Type of document: □ ID card □ passport □ officer's license □ other

Relationship with the patient: □ spouse □ child □ parent □ other close relatives □ colleague □ friend □ other: _____________

Client Statement:

I was hospitalized on __________ ____ ____ due to an illness. During the period of my hospitalization, I have fully authorized _____________ to act as my attorney, to exercise my rights of informed consent and choice of treatment plan on behalf of me in respect of all treatment services provided by the medical practitioner, and to sign the relevant medical documents on my behalf. The signature of the delegate is deemed to be my signature.

I make the above authorization on a completely voluntary basis to the appointee, the appointee to engage in the entrusted activities arising from the consequences, fully borne by me.

Signature or handprint of the delegator (patient): Date: Month of the year Signature of the delegatee: Date: Month of the year

Note: The delegator refers to the patient with full civil behavior, the guardian of the patient who does not have full capacity for civil behavior. This authorization letter needs to be saved in the medical record at the same time with the relevant consent form; a copy of the valid identity card pasted on the reverse side of this power of attorney.

Patient Power of Attorney 9

Name Hospitalization No.

I entrust _____________________ as my agent during my treatment at _____________________ hospital, to exercise on my behalf the right of informed consent during my treatment at your hospital in relation to my condition, diagnosis, therapeutic measures, medical risks, medical expenses and other matters.

These are the only way to get the best out of your hospital.

Name of client ________________ Gender _____ Age _____ Occupation _____________________

Work unit ___________________________ Address ______________________________

Signature (seal) of the principal ____________________________

Name of the agent ___________ gender _______ age _______ occupation ______________________

Workplace __________________________ Address _______________________________

Relationship with the principal __________________ Contact details _____________________________

Signature of the agent (seal) ___________________________

Year, month, day, hour and minute

Remarks

Hospital outpatient number ________

Section _______________ Informed Consent for Surgery Hospitalization No. _________

The patient _______________ was admitted to bed _________ in ward __________ due to illness,

The preoperative diagnosis (proposed diagnosis) was _____________________________________________________

Surgery is recommended (proposed) to be performed _______________________________________________________,

Signature of the physician: __________

I agree to the surgical treatment of the patient, as I am aware of the above conditions.

Signature of the patient:____________________

Or signature of the agent:_______________________ Relationship with the patient:_____________________

Or signature of the person in charge of the unit:____________ Position. __________ Work Unit: _________________

Month and year

Note: In addition to the patient does not have full capacity for civil behavior, not the patient's own signature must be signed by the authorization of the power of attorney, the power of attorney on the patient's designated agent to sign.

Patient Power of Attorney 10

Principal: ___________

Trustee: ___________

Patient's name ___________ gender _____ age ____ department ___________ case number ___________ I am on the ___________ year. ___________ month ___________ day was admitted to ___________ hospital due to ___________ illness. In accordance with the relevant legal provisions, I appoint ___________ as my agent to represent me in exercising my right to make medical informed consent choice decisions during my current hospitalization. The reason I am appointing this person is __________.

Principal: ___________

Trustee: ___________

Date: _____________

Patient Power of Attorney 11

I hereby delegate as my agent during my treatment in the hospital, to exercise the right of informed consent on my behalf for the treatment and treatment of my medical condition, medical treatment, medical risks and other matters. The patient's authorization is not a form of consent, but rather a form of consent.

Name of client: Gender: Age:

Workplace: Occupation: Residential address:

Identity document and number:

Name of proxy: Gender: Age:

Workplace: Occupation: Residential address:

Identity document and number:

Signature of client:

Time: Day, hour, minute

Time: Time: Day, hour, minute, minute, minute, minute, minute, minute, minute Signature of the proxy:

Time: Month day, hour