Medical Authorization

Medical Authorization

Download AED Medical Authorization Form(PDF)

The Food & Drug Administration considers LIFEPAK® defibrillators and some of the accessories required to operate them (including electrodes) to be prescription devices pursuant to 21 CFR 801.109. Physician / Medical authorization is required. Most states provide immunity from civil liability to the physician prescribing an AED. State legislation can be accessed through your state‚Äôs website or medical board.

This serves as Medical Authorization for External Defibrillators and Automated External Defibrillators (AEDs) and the accessories required to operate them (including electrodes) as indicated below.

Recipient of the AED Medical Authorization [check appropriate box(es)]: 

  INDIVIDUAL
  BUSINESS OR NON-PROFIT ORGANIZATION
  GOVERMENT AGENCY

Name of recipient of AED(s):

Address for each location at which an AED will be located:

Location Name:
Street:
City/State/Zip:
Phone Number:
Contact/Title:

If more locations are provided for under this Medical Authorization, please attach a separate piece of paper listing the required contact information for each location.




List any restrictions to this Medical Authorization, if applicable:

Authorizing Physician or Licensed Practitioner: [please print]

Name:
Street:
City/State/Zip:
Phone Number:
Fax Number:
Signature:
Date:

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