Medical Release Form For Minors Attending With A Guardian

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Medical Release Form for Minors Attending With A Guardian
Name of Minor Child: _______________________________ Age: _________ Date of Birth: _______________
We, the undersigned parent(s) or legal guardian(s) of the above-named minor, know that I may not be available to
authorize medical care of said minor child and I wish to appoint someone to act in my place in my absence and to
give such authorization. This authorization is intended to give ______________________________ (name of
guardian over 18) the right to give consent to authorize emergency medical care.
It is intended that this document be presented to the physician or appropriate hospital or medical representative at
such times as the medical care shall be authorized. It is intended that this authorization relieve the physician,
dentist, or other person rendering such care at the hospital or institution in which such care is given, from any liability
resulting from the failure of me, the parent or guardian of the above-named minor, from signing a consent or
authorization to render such care. It is the intent that the above named guardian shall act in my stead in making
such decisions.
I have put the important medical facts, if any, on this form. The medical facts are intended to help the doctor in
deciding what treatment is to be given, but are in no way intended to restrict the giving of authorization or consent by
the above named guardian. I understand that this form is in effect from the date signed and that it is my
responsibility to inform MWMA, Inc. of any changes to this form.
______________________________ ________________
(Signature of Parent)
(Date)
______________________________ ________________
(Signature of Guardian over 18)
(Date)
Emergency Contact Information:
Parent Name: _________________________________________
Home Phone: ______________________
Address: _________________________________________
City/State/Zip: _____________________________
Work Phone: _______________________
Cell Phone: _____________________________
Health Insurance Information:
Company or Organization: _____________________________________________________________________
Address: _________________________________________
City/State/Zip: _____________________________
Name of Policy Holder: _______________________________________________________________________
Policy or Contract Number:___________________________
Expiration Date: ________________________
Physician Information:
Physician Name: ________________________________________ Phone: ______________________
Address: _________________________________________
City/State/Zip: _____________________________

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