If the client has not made any rights and interests that violate the laws of the state, the client shall not break his word for any reason when exercising his power. In today's social life, we need a power of attorney to handle affairs. I believe that writing a power of attorney is a headache for many people. The following is a patient's power of attorney compiled by me for your reference only. Let's have a look.
Power of Attorney for Patient 1 Client (patient himself):
Name: xxxxxxx Gender: xx Age: xx Tel: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Trustee information:
Name: xxxxxxx Gender: xx Age: xx Tel: xxxxxxxxX ID number: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Xxxxxx was admitted to Deqing County Hospital of Traditional Chinese Medicine due to illness. In order to ensure that the diagnosis and treatment activities carried out by the hospital can be carried out smoothly, and to realize my right of informed consent during this hospitalization, I solemnly entrust XXXXXX.
As my agent, authorize me to: (1) understand the illness on my behalf; (two) to exercise the right of informed consent during hospitalization, and to perform the corresponding signature procedures, including the following circumstances:
When performing anesthesia, surgery and invasive examination and treatment on yourself;
When using expensive drugs, consumables or conducting expensive tests;
When blood and blood products need to be infused due to illness;
I am temporarily incapable of informed consent, but my condition needs corresponding treatment.
Patient's signature: year month day.
Signature of the trustee: year month day.
Power of attorney of patient 2' s client: _ _ _ _ _ _ _ _
Trustee: _ _ _ _ _ _ _
I was admitted to the hospital in _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. In order to ensure the smooth implementation of the hospital's diagnosis and treatment activities and realize my right of informed consent during this hospitalization, I solemnly entrust him as my agent and authorize him to:
1. means I understand my illness;
2. Exercise the right of informed consent during hospitalization and perform the corresponding signature procedures, including the following:
(1) Perform anesthesia, surgery, invasive examination and treatment for yourself;
(2) When using expensive drugs, consumables or conducting expensive inspection;
(3) I belong to public medical care, rural cooperative medical care, social security patients and other expenses, using specific drugs or taking specific medical measures beyond the scope of reimbursement for disease diagnosis and treatment;
(four) when blood and blood products need to be infused due to illness, and when experimental treatment is carried out;
(5) because of the critical condition, temporarily without informed consent ability but need emergency treatment.
Principal: _ _ _ _ _ _ _
Trustee: _ _ _ _ _ _ _
Date: _ _ _ _ _ _
Power of attorney of client (patient himself) of patient 3: name, gender, age, bed number, hospitalization number and address.
Telephone ID number
Parties: name, gender, age, relationship between work unit and patient, and address.
Telephone ID number
I was admitted to the hospital on 1 1 month 15. In order to ensure the smooth implementation of the hospital's diagnosis and treatment activities and realize my right of informed consent during this hospitalization, I solemnly entrust him as my agent and authorize him to:
1. means I understand my illness;
2. Exercise the right of informed consent during hospitalization and perform the corresponding signature procedures, including the following:
(1) Perform anesthesia, surgery, invasive examination and treatment for yourself; (2) When using expensive drugs, consumables or conducting expensive inspection;
(3) I belong to public medical care, rural cooperative medical care, social security patients and other expenses, using specific drugs or taking specific medical measures beyond the scope of reimbursement for disease diagnosis and treatment;
(four) when blood and blood products need to be infused due to illness, and when experimental treatment is carried out; (5) because of the critical condition, temporarily without informed consent ability but need emergency treatment.
Signature of the client: (handprint) MM DD YY.
Signature of the Client: (handprint) MM DD YY.
Power of Attorney for Patient 4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ The reason why I entrusted this person is: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Valid ID number: Address:
Trustee: sex and age Tel: valid ID number: Address: Relationship with patient: □ spouse □ children □ parents □ other close relatives □ colleagues □ friends.
The authority of the trustee is: to know the patient's condition, medical measures and medical risks on his behalf; Exercise the right to choose and decide on behalf of the informed consent of medical treatment, and perform the corresponding signing procedures, including the following situations:
-Anesthesia, surgery, special examination and treatment for patients themselves;
-when the condition changes and rescue is needed;
-Emergency rescue or accidents during the operation need to change the scheduled operation and operation plan, emergency blood transfusion, removal of organs or larger tissues, and ligation of important blood vessels;
□ When using expensive drugs, consumables or carrying out special inspection with high price;
□ Patients with different types of insurance, such as free medical care, social medical insurance for serious illness, and new rural cooperative medical system, use specific drugs or take specific medical measures to diagnose and treat diseases beyond the prescribed reimbursement scope;
-need to give the patient himself blood transfusion, blood products, experimental treatment;
□ When medical biomaterials such as artificial organs need to be implanted;
-Other family members of the patient refused to use the diagnosis and treatment drugs and treatment measures given according to the condition.
□ Other conditions encountered in surgical treatment and diagnosis and treatment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Patient's signature: _ _ _ _ _ _ _
Signature time: year, month, day, month, signature place:
I confirm and accept that the patient _ _ _ _ _ _ _ authorized me to exercise the decision-making power of medical informed consent during this hospitalization, including knowing the patient's condition, medical measures and medical risks on his behalf; Exercise the right to choose and decide on behalf of the informed consent of medical treatment, and perform the corresponding signing procedures.
Signature of trustee: _ _ _ _ _ _ ID number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Note: It is recommended to use two copies, one for the patient and one for the medical record.
Patient's power of attorney 5] Name, gender, age, ward bed number and hospitalization number
Name of client (patient): valid ID number: ID card, passport, military officer's card, etc.
Customer name: gender, age, telephone number:
Valid ID number: ID type: oral ID card, passport, officer ID card, other.
Relationship with patients: spouse, children, parents, other relatives, colleagues, friends, others;
Customer statement:
I was hospitalized because of illness. During my stay in hospital, I was authorized to act as my agent, exercise my right to informed consent and choose the treatment plan on my behalf, and sign relevant medical documents on my behalf. The signature of the principal shall be deemed as my signature.
I made the above authorization to the client on a completely voluntary basis, and the client engaged in entrusted activities.
I will bear the consequences completely.
Signature or handprint of the client (patient): date: year month day.
Signature of the client: date: year month day.
Note: Clients refer to patients with full capacity for civil conduct and guardians of patients without full capacity for civil conduct. This power of attorney
It must be kept in the medical record with the relevant consent; A copy of valid identification shall be affixed on the back of this power of attorney.
Power of Attorney for Patient 6 Patient's name, gender, age and medical record number
I was admitted to the northern hospital because of illness. According to the relevant laws and regulations, I entrust _ _ _ _ _ _ _ as my agent to exercise the right of informed consent for medical treatment during my hospitalization.
The reason why I entrusted this person is _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. Party (patient himself): name, gender and age.
Valid ID number (ID card):
Trustee: Gender and Age Tel:
Number of valid certificate (ID card):
Relationship with patients: □ spouse □ children □ parents □ other close relatives □ colleagues □ friends.
The authority of the trustee is: to know the patient's condition, medical measures and medical risks on his behalf; Exercise the right to choose and decide on behalf of the informed consent of medical treatment, and perform the corresponding signing procedures, including the following situations:
-Anesthesia, surgery, special examination and treatment for patients themselves;
-when the condition changes and rescue is needed;
-Emergency rescue or accidents during the operation need to change the scheduled operation and operation plan, emergency blood transfusion, removal of organs or larger tissues, and ligation of important blood vessels;
□ When using expensive drugs, consumables or carrying out special inspection with high price;
□ Patients with different types of insurance, such as free medical care, social medical insurance for serious illness, and new rural cooperative medical system, use specific drugs or take specific medical measures for the diagnosis and treatment of diseases beyond the prescribed reimbursement scope;
-need to give the patient himself blood transfusion, blood products, experimental treatment;
□ When medical biomaterials such as artificial organs need to be implanted;
-Other family members of the patient refused to use the diagnosis and treatment drugs and treatment measures given according to the condition.
□ Other circumstances encountered in surgical treatment and diagnosis and treatment: _ _ _ _ _ _ _.
Patient signature:
Signature time: year, month, day, month, signature place:
I confirm and accept the patient, including understanding the patient's condition, medical measures, medical risks and so on. Exercise the right to choose and decide on behalf of the informed consent of medical treatment, and perform the corresponding signing procedures.
Signature of the trustee:
Signature time: year, month, day, month, signature place:
Note: It is recommended to use two copies, one for the patient and one for the medical record.
Power of Attorney for Patient 7 Patient name _ _ _ _ _ _ _ Patient name _ _ _ _ _ _ _ Patient name
Client (patient himself): gender and age
Valid ID number: Address: Trustee: Sex and age Tel: Valid ID number: Address: Relationship with patients: □ spouse □ children □ parents □ other close relatives □ colleagues □ friends.
The authority of the trustee is: to know the patient's condition, medical measures and medical risks on his behalf; Exercise the right to choose and decide on behalf of the informed consent of medical treatment, and perform the corresponding signing procedures, including the following situations:
-Anesthesia, surgery, special examination and treatment for patients themselves;
-when the condition changes and rescue is needed;
-Emergency rescue or accidents during the operation need to change the scheduled operation and operation plan, emergency blood transfusion, removal of organs or larger tissues, and ligation of important blood vessels;
□ When using expensive drugs, consumables or carrying out special inspection with high price;
□ Patients with different types of insurance, such as free medical care, social medical insurance for serious illness, and new rural cooperative medical system, use specific drugs or take specific medical measures for the diagnosis and treatment of diseases beyond the prescribed reimbursement scope;
-need to give the patient himself blood transfusion, blood products, experimental treatment;
□ When medical biomaterials such as artificial organs need to be implanted;
-Other family members of the patient refused to use the diagnosis and treatment drugs and treatment measures given according to the condition.
□ Other conditions encountered in surgical treatment and diagnosis and treatment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Patient's signature: _ _ _ _ _ _ _
Signature time: _ _ _ _ _ _ _ _ _ _ _ _
Signature place:
Patient 8 Power of Attorney Client (patient) Name: _ _ _ _ _ _ _ Valid ID number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ □□□
Name of the entrusted party: _ _ _ _ _ _ _ _ _ _ _ _ Gender: _ _ _ _ _ _ Age: _ _ _ _ _ _ _ _ Tel: _ _ _ _ _ _ _ _ Valid ID number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Relationship with patients: □ spouse □ children □ parents □ other close relatives □ colleagues □ friends □ others: _ _ _ _ _ _
Customer statement:
I was hospitalized on _ _ _ _ _ _ _ _ _. During my hospitalization, I authorize _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I made the above authorization to the client on a completely voluntary basis, and the consequences arising from the activities entrusted by the client are entirely borne by me.
Signature or handprint of the client (patient): Date: MM DD Signature of the client: Date: MM DD DD.
Note: Clients refer to patients with full capacity for civil conduct and guardians of patients without full capacity for civil conduct. This authorization must be kept in the medical record together with the relevant consent; A copy of valid identification is posted on the back of this power of attorney.
Patient's power of attorney 9 Name and hospital number
I entrust _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Customer name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Work unit: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Signature (seal) of the person in charge _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Agent's name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Work unit: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
The relationship with the principal _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Signature (Seal) of Agent _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date time
comment
Hospital outpatient number _ _ _ _ _
Department _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Patient _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Preoperative diagnosis (to be diagnosed) as _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ refers to
Suggest (go to) execute _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
And explain the possible complications and surgical risks during or after operation to patients or relatives;
Signature of doctor: _ _ _ _ _ _ _
Understand the above situation and agree to surgical treatment.
Patient's signature: _ _ _ _ _ _ _ _ _ _ _ _
Or signature of agent: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Or the signature of the person in charge of the unit: _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ Work unit: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date, year and month
Note: Unless the patient does not have full capacity for civil conduct, the person who is not signed by the patient must first sign the power of attorney, which is signed by the agent designated by the patient.
Patient's power of attorney 10 Client: _ _ _ _ _ _ _ _
Trustee: _ _ _ _ _ _ _
Patient's name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ According to the relevant laws and regulations, I entrust _ _ _ _ _ _ _ as my agent to exercise the right of informed consent for medical treatment during my hospitalization. The reason why I entrusted this person is _ _ _ _ _ _.
Principal: _ _ _ _ _ _ _
Trustee: _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _
Power of attorney for patients 1 1 I hereby entrust to act as my agent during the diagnosis and treatment in our hospital, and exercise the right of informed consent on behalf of me on matters related to illness, medical measures and medical risks.
Customer Name: Gender: Age:
Work unit: occupation: address:
Identification document and number:
Name of Agent: Gender: Age:
Work unit: occupation: address:
Identification document and number:
Customer's signature:
Time: year, month, day and time.
Signature of agent:
Time: year, month, day and time.