Stysa Medical Release Form

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MEDICAL RELEASE FORM
As the parent/guardian of _________________________________________, I request that in
my absence the above player be admitted to any hospital or medical facility for diagnosis and
treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of
Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any
diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the
above minor. I have not been given a guarantee as to the results of examination or treatment.
I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the
above-named player.
Birth Date of Player____/____/____ Date of last Tetanus Booster____/____/____
Known allergies of this player, including any allergies to medicine______________________
___________________________________________________________________________
Any other medical problems which should be noted__________________________________
___________________________________________________________________________
Family Physician_______________________________ Phone #_______________________
Insurance Carrier________________________________ Policy Number________________
Name of Parent/Guardian_______________________________________________________
Address_____________________________________________________________________
City/State/Zip________________________________________________________________
Home Phone________________ Work Phone________________ FAX_________________
Person responsible for charges (if different than above)_______________________________
Address_____________________________________________________________________
City/State/Zip________________________________________________________________
Home Phone________________ Work Phone________________ FAX__________________
Person to notify if parent/guardian is unavailable____________________________________
Home Phone________________ Work Phone________________ FAX__________________
Signature of Parent/Guardian____________________________________________________
Revised: 07/2005 STYSA, 15209 Highway 290 East, Manor, TX 78653 512/272-4553

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