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
State of --) ) SS. County of --) On -- before me, --, personally (Date) (Notary) appeared -- Signer(s) Personally known to me - OR - proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same...