Common use of Consent for Emergency Treatment Clause in Contracts

Consent for Emergency Treatment. I authorize the University of Wisconsin-Madison, the Xxxxx Xxxxxxxx American Family Insurance Foundation, and the American Family Mutual Insurance Company, S.I and their designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin-Madison, the Xxxxx Xxxxxxxx American Family Insurance Foundation, and the American Family Mutual Insurance Company, S.I (list other groups) and their designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physicianphysician to my child/xxxx. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date:: ____________________

Consent for Emergency Treatment. I authorize the University of Wisconsin-Madison, Waisman Center and Friends of the Xxxxx Xxxxxxxx American Family Insurance Foundation, and the American Family Mutual Insurance Company, S.I Waisman Center and their designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: