1. I, ______________________, am _________ years of age and a resident of
___________________________________.
2. I authorize Greater Europe Mission through its agents and/or employees to consent to any
x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care
which is deemed advisable by, and is to be rendered under the general or special supervision
of, any physician and surgeon duly licensed under the provisions of the Medical Practice Act
on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at
said office of said physician or at said hospital, and/or any dentist duly licensed under the
provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at the
office of said dentist or at said hospital.
3. I authorize Greater Europe Mission through its agents and/or employees, to consent to any x-ray
examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable
by, and is to be rendered under the general or special supervision of, any physician and surgeon duly licensed
under the provisions in effect in the foreign state/province, country or other state within the United States, where
the care is rendered, on the medical staff of a hospital whether such diagnosis or treatment is rendered at office
of said physician or at said hospital, and/or any dentist duly licensed under the provisions in effect in the foreign
state/province, country or other state within the United States, where the care is rendered, whether such
diagnosis or treatment is rendered at the office of the said dentist or at said hospital.
4. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care
being required, but is given to provide authority and power of the aforesaid agents and/or employees to give
specific consent to any and all diagnosis, treatment, or hospital care which the physicians and/or dentists, in the
exercise of their best judgment, may deem advisable and necessary.
5. I understand that the licensing procedure in foreign countries and medical and/or dental care in foreign
countries may not be of the same standards and quality as found within the United States.
6. This authorization is given with the understanding that foreign doctors and doctors in other states within the
United States are not licensed under the Medical Practice Act and that foreign dentists and dentists in other
states within the United States are not licensed under the Dental Practice Act. This authorization shall remain in
effect until _________________________, (date after last day of project) unless revoked sooner in writing and
delivered to said agent and/or employee of EuroTeam. A photocopy, carbon copy, faxed copy or copy
downloaded from e-mail (electronic mail) of this document will have the same force and effect as an original.
7. I am covered under the following health insurance plan(s):
Plan Group Nr. is __________________________________.
8. My health care coverage as indicated above is valid and will remain in effect while I am traveling in foreign
countries and/or other states within the United States. (X )Yes ( ) No
9. I understand that should it become necessary for medical and/or dental care to be provided, the authorizing
agent and/or employee of Greater Europe Mission assume no responsibility for payment of any and all
expenses which may be incurred. I understand that I am fully responsible for payment of all medical and/or
dental costs and/or fees which may be incurred. I agree to hold harmless the authorizing agent and/or employee
of Greater Europe Mission from any liability for payment for said care, should it be authorized.
10. Please give the following specific information or instructions to physician and/or dentist or nurse:
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