1、雅致东方酒店ELEGANT ORIENTA HOTEL购药授权书Authorization Medicament PurchasingGuest: of Room: staying from: To 客人 _ 房号_入住日期自_至_Prescription / 处方药 Over The Counter / 非处方药You might be rejected by the Medical Shop as without prescription paper form Doctor. The shop has the right to reject by law如果您不能出示医生的处方，药店有权拒
2、绝出售您所需要的药物。Medicine description / Name: Quantity: 药物描述/药名 数量 Signature as confirmation Time Setout Time Return签字确认 ： 接待时间 : 返回时间: I have received that medicament of the above captioned that purchased by Elegant orienta hotel under my authority. And I hereby acknowledge that I am personal liable for
3、any aftereffect from the medicament and Elegant orienta hotel will not be liable for any blights caused by the medicament.本人确认已收到委托雅致东方酒店所代购的药物, 并对由于服用所购药物后可能产生的一切后果承担法律责任. 相反, 雅致东方酒店将不承担任何责任.The signature underneath certifies my legal capacity and that stands for the acceptance to the above terms & conditions.以下之签署代表本人完全接受以上条款.Gust Signature 宾客签字 : _ Date 日期: _Handled by:代办人签字 : _ AM signature 大堂副理签字:_
