MEDICAL AUTHORIZATION

          You are hereby authorized to furnish to my attorney, LEONARD E. COX, of League City, Texas, or any of his legal associates, and/or investigative agents, or anyone whom he may designate, any information he may request including films, and/or any other studies and any information concerning costs and expenses incurred for medical treatment.

          Should any of the designated persons request a written report, x-ray, films or results of any studies performed by you, I would appreciate your furnishing such and/or written report.

          A copy of this document including my signature presented by LEONARD E. COX, et al as mentioned herein I have the same force and  effect as an original.

          This document shall be effective from the date hereof until terminated in writing by LEONARD E. COX or the undersigned.

 

Dated this ________ day of ___________________, 20___________.

                                     

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                                                                   Signature

 

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                                                                   Date of Birth

 

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                                                                   Social Security Number