MoonRise Therapeutics Emergency Medical Treatment Authorization

Emergency Medical Treatment Consent Plan

In the event emergency medical aid/treatment is required due to illness or injury while being on the property at MoonRise Farm I authorize MoonRise Therapeutics staff or volunteers to secure and retain medical treatment and transportation if needed. This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “ life saving” by the physician.

Name (required)

DOB#3 (required)

Parent Guardian Information ( if under 18) Name#4 (required)

Address (required)

Phone (required)

Email(required)

Emergency Contact Full Name (required)

Emergency Contact Phone Number(required)

Physician Name and Phone Number (required)

Preferred Medical Facility (required)

Health Insurance Company (required)

Health Insurance Policy Name and Number (required)

Health History Please describe any information that would be necessary for doctors to know should you need emergency services

Medications

Allergies

Seizures

Date of Last Tetanus Shot

Electronic Signature(required)

I/WE HAVE READ THE ABOVE, "MOONRISE THERAPEUTICS, ASSUMPTION OF RISK POLICY".I UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE NOT CHANGED IT ORALLY, AND SIGN IT VOLUNTARILY. I agree to sign the agreement electronically by typing in my name below.

Type Your Name as Your Electronic Signature(required)

Emergency Medical Treatment Non-Consent Plan

Parent or legal guardian will remain on site at all times during the process of receiving services or while being on the property of the agency. I do not give my consent for emergency medical treatment/aid in the case of illness or injury.