Elysium, Medical Release Form

original movie prop

Please, sign this to receive medication.

After being accidentally subjected to a fatal radiation dose at the Armadyne plant where he works, Max Da Costa is given a quick exam by an Armadyne company medical droid, judged to be terminal, made to sign a release form, and given some pills to keep him going for the few days he has left.

Paper forms, in Spanish, one of which has a scrawl in pen which appears identical to the small section of Da Costa's 'signature' glimpsed in the scene.

From VIP Fan Auctions & MRC.