This authorization permits ( print you or your company name) to purchase ( fill in number) AED Units, Brand of AED: under the following terms and conditions:
Client’s Responsibilities. Client shall be responsible for assigning staff with training in their hometown or each facility by a qualified CPR and AED Training company OR have CPR and Sports Medicine Services, LLC set up part of the AED program (AED Coordinator ) to insure compliance with local and national protocols and regulations. Compliance with local and national protocols and regulations is the sole responsibility of the coordinator. (State Legislation is at www.aedhelp.com. By signing this form, the coordinator agrees they are following these laws.) The following AED protocol is for use by your ERT (Emergency Response Team) or AED Team. Although Good Samaritan Regulations provide significant civil protection to individuals utilizing an AED; you need to set up your own AED program and medical direction under a physician’s orders.
IF KNOWN, please indicate the training program materials you will use. If unknown at this time, please provide this information to CPR and Sports Medicine Services, LLC before the purchase of your AED.
AED Coordinator’s Name
( Your company)
On-Site AED Coordinator’s name
MEDICAL AUTHORIZATION TO PURCHASE AUTOMATED EXTERNAL DEFIBRILLATOR- By printing and signing below, I hereby attest that I have set up medical authorization and have medical direction guiding us in the aed set-up and emergency plan use. I understand that a defibrillator is a medical devise and will be treated as such.
Please check off if
you are using a check or credit card below: