Principal (the patient himself): name gender age bed number hospitalization number address
Telephone ID card number
Appointee: name gender age work unit and the patient's relationship with the address
Telephone ID card number
I was admitted to the hospital in the year on the day of the month. In order to ensure that the hospital for me to implement the diagnosis and treatment activities can be carried out smoothly, at the same time, in order to realize my right to informed consent during this hospitalization, I solemnly entrusted as my agent, authorized to:
1. on behalf of the understanding of my condition;
2. on behalf of the exercise of the right to informed consent during the hospitalization, and the implementation of the corresponding signing formalities, including the following circumstances:
① anesthesia, surgery, and invasive examination and treatment of me;
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 and other fees, in order to diagnose and treat the disease beyond the scope of the reimbursement for the use of specific medicines or specific medical measures;
④ because of the condition of the need to me When transfusing blood and blood products and taking experimental treatment for me;
⑤ When I am temporarily incapable of giving informed consent but need urgent treatment due to my critical condition
Signature of the principal: (Handprint) Month/Year
Signature of the appointee: (Handprint) Month/Year
Declaration of the principal:
I was hospitalized on the day of January, 2012 due to my illness. I was hospitalized, I fully entrusted as my agent, on behalf of me to provide all diagnostic and treatment services, exercise informed consent and diagnostic and treatment options and other rights, and on behalf of me to sign the relevant medical instruments. The signature of the authorized person shall be deemed to be my signature.
Write down clearly the principal, entrusted matters, entrusted information and time
Legal basis: "People's Republic of China *** and the National Code," Article 154 of the following circumstances, the relevant part of the estate in accordance with the legal inheritance: (a) the testamentary heir to give up the inheritance or bequeathed to give up the (a) The testamentary heir abandons the right to inherit or the legatee abandons the right to bequeath; (b) The testamentary heir loses the right to inherit or the legatee loses the right to bequeath;