Automatic External Defibrillator
(AED) Medical Authorization
The food and drug administration considers defibrillators to be prescription devices pursuant to 21 CFR 801.109 and medical
authorization is required.
This document provides Medical Authorization for one or more Automatic External Defibrillator(s) ("AED(s)") as indicated below.
1. Recipient of the AED Medical Authorization (check all that apply):
__ Individual/Patient
__ Business: number of locations: _______
2. Name of recipient of AED(s):__________________________________________________
3. Address for each AED location:
Location Name:_______________________________________________________________
Street:______________________________________________________________________
City/State/Zip:________________________________________________________________                   
Phone Number:_______________________________________________________________
Contact/Title_________________________________________________________________
Location Name:_______________________________________________________________
Street:______________________________________________________________________
City/State/Zip:________________________________________________________________
Phone Number:_______________________________________________________________
Contact/Title_________________________________________________________________
If more locations are provided for under this medical authorization, please attach a separate sheet of paper listing the
required contact information for each location.
List any restrictions to this Medical Authorization, if applicable:_____________________________
________________________________________________________________________________
Authorizing Physician (please print):
Name:____________________________________________________________________
Street:____________________________________________________________________
City/State/Zip:______________________________________________________________
Phone & Fax Numbers:_______________________________________________________

Physician's Signature:________________________________________________________
Return to:
LifeSavers, Inc.
39 Plymouth St. Fairfield, NJ 07004
Phone: (973) 244-9111 Fax: (973) 244-1666