I hereby authorize Knospe-Lerncenter GmbH to administer the medical measures listed below, as and when deemed necessary.
Please list medications, dosage, frequency, and other instructions for administration.
3. Right to Revoke
I understand that I have the right to revoke this authorization at any time by providing written notice to Knospe-Lerncenter GmbH. I understand that by revoking this authorization, Knospe-Lerncenter GmbH may not be able to provide certain treatments in the event they are required.
4. Authorization Validity
This authorization replaces and supersedes all previous medical release forms to the patient. By signing this form, I acknowledge that any prior permissions or restrictions I may have set are null and void.
This authorization will remain in effect until discharge from Knospe-Lerncenter GmbH, unless I request an earlier expiration date here:
Thereafter, this authorization becomes null and void.
5. Contact Information for Questions
If you have questions about this authorization or need to revoke it, please contact:
Georgstr 2, 31675 Bückeburg, Deutschland
Phone: +49 5722 9098399
Email: [email protected]
I have read and understood this authorization form. I understand that I have a right to receive a copy of this authorization. I understand that in case of any injury, an Incident Report will be available to me.
By signing below, I agree to the terms and conditions outlined above.