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Appendix B: hospital visitation authorization.

Life Lines: Documents to Protect You and Your Family in Times of Trouble

| January 01, 2003 | COPYRIGHT 2003 National Center for Lesbian Rights. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan.  All inquiries regarding rights should be directed to the Gale Group. (Hide copyright information)Copyright

HOSPITAL VISITATION AUTHORIZATION

I, --, a resident of -- County, State of --, do hereby give notice and authorize that, if any injury or illness, or any incapacity through any other cause necessitates my hospitalization or treatment in a medical facility, it is my wish that -- be given first preference in being admitted to visit me in such facility, whether or not there are parties related to me by blood or by law or other parties desiring to visit me, unless and until I freely give contrary instructions to competent medical personnel on the premises involved.

Executed this -- day of --, 20 --, at

--.

--

Signature of Principal

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

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