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Please fill in this form and email or fax it to Shawn Roney, CPR and Sports Medicine Services, LLC at Fax: 866-469-9443 or email: info@cprflorida.net

MEDICAL AUTHORIZATION TO PURCHASE AUTOMATED EXTERNAL DEFIBRILLATOR

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.

TRAINING PROGRAM INFORMATION:
Client agrees that all personnel authorized to use the AED will be trained utilizing a training program that conforms to nationally recognized standards for CPR and AED, and that meets state requirements for AED training.

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.

Please indicate the training materials and organization you will use or have used:
• American Heart Association
• American Red Cross
• American Safety and Health Institute
• Other CPR organization name

AED Coordinator’s Name

Authorized Title

Coordinator’s Signature and/or type in initials: X______________________________

Date

Client or main company address:

( Your company)

(street)

(city) (state)

(zip)

Phone Number

Fax Number

E-mail

SITE LOCATIONS
(Note : Depending on the number of site locations covered under this agreement,
print pages as needed.) Tell where the AED will be located or sold to:

1. Site Address:

(company)

(street)

(city) (state)

(zip)

Number of AEDs at Site Planned number of trained responders

On-Site AED Coordinator’s name

Phone: Fax

E-Mail Address

Physician Approval: This is needed for most brands of AEDS.

(Physician name)

(State License # )

X ________________________________________________ (Physician’s signature in pen)

X ______________________________ (Print date in pen).

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.

Date Brand of AED:
Number of Units:

X ________________________________________________ (Print/type and sign. Person’s name in charge of the AED and/or purchaser of the AED.)

date X ______________________________ (Print date in pen).

Please check off if you are using a check or credit card below:

Credit card Check

Thank you.

Shawn Roney