Medical Release Form

MEDICAL TREATMENT RELEASE FORM

As parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.

* Indicates required field

Name of Minor(s) *

First

Last

Address of Minor(s) *

Line 1

Line 2

City

State

Zip Code

Country

Relationship to you *

Emergency Phone Number *

Name of Family Physician *

Physician Phone Number *

Physician Address and City *

List allergies, medication, contract, or other pertinent comments *

Health Insurance Provider *

Group *

Policy *

Contact *

I further authorize the person who presents the minor to sign the Acknowledgment of Receip of Notice Privacy Rights that may be presented by the physician or health care facility.
This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.

Date *

Signed by *

Parent or Guardian

Submit