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1. Date and Location: Current date and place where the letter is being written
2. Subject Line: Clear indication that this is a Medical Authorization Letter for Pregnancy-Related Care
3. Pregnant Woman's Details: Full name, ID number, contact information, and current residential address of the pregnant woman
4. Authorized Party Details: Full name(s), ID number(s), and contact information of the person(s) being authorized to make decisions
5. Scope of Authorization: Specific medical decisions and actions being authorized, including routine care, emergency procedures, and specific treatments
6. Duration of Authorization: Time period for which the authorization is valid, typically covering the pregnancy period and immediate postpartum care
7. Medical Information: Relevant medical details including expected due date, treating physician, and hospital/facility details
8. Declaration of Sound Mind: Statement confirming the pregnant woman is of sound mind and making this authorization voluntarily
9. Signature Block: Space for signatures of the pregnant woman, authorized parties, and witnesses
1. Special Medical Conditions: Section detailing any specific medical conditions, allergies, or complications that healthcare providers should be aware of
2. Religious or Cultural Preferences: Specific religious or cultural considerations that should be respected during medical care
3. Alternative Authorized Parties: Secondary or tertiary authorized persons in case primary authorized person is unavailable
4. Revocation Clause: Specific terms under which the authorization can be revoked by the pregnant woman
5. Language Preference: Preferred language for medical communication, particularly relevant in multi-lingual South Africa
1. Medical History Summary: Brief summary of relevant medical history, previous pregnancies, and current pregnancy details
2. Emergency Contact List: Prioritized list of emergency contacts with their full contact details and relationship to the pregnant woman
3. Copy of Identity Documents: Copies of ID documents of both the pregnant woman and authorized parties
4. Healthcare Provider Details: List of current healthcare providers, including obstetrician, GP, and chosen hospital or birthing facility
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