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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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