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   Hospital Visitation Authorization

    

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Hospital Visitation Authorization

I, ________________________________, residing at ___________________________________, in the city of ______________________________ in _____________________________ County, in the state of ___________________, do hereby swear and depose as to the following information:

Should I become incapacitated, fall ill, become injured, be admitted to a hospital or require care at any medical facility, my desire is that __________________________ be admitted to visit me first and foremost.

That ____________________________ take precedent over any other visitors who wish to see me, even if those persons have blood ties or legal connections to me.

That this authorization be upheld unless I willingly, and being of sound mind, give contrary instructions to competent medical personnel.



____________________________________
Signature & date



_______________________________________
Witness

Address_____________________________

City, state, ZIP________________________



_______________________________________
Witness

Address_____________________________

City, state, ZIP________________________

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