Medical Release Form printable pdf download

Medical Release Form

Child’s Name:_______________________________Parent/Legal Guardian.s Name: ______________________________

Address: ______________________________________________________________________ Child’s BDay__________

Phone #s: Home (________) ________ - _______________

Allergies:

Work (________) ________ - _______________

Cell (________) ________ - _______________

Other (________) ________ - _______________

In an emergency, please contact: ________________________

Relationship to child/children: ___________________________

Phone #s: (________) ________ - _______________

(________)________ - _______________

Physician.s Name: ___________________________________________________________________

Address: _______________________________________Phone #s: (________) ________ - _______________

Dentist.s Name: ______________________________________________________________________

Address: ________________________________Phone #s: (________) ______ - _______________

Primary Insurance Company: _________________________________________________________

Phone #s: (________) ________ - _______________ (________) ________ - _______________

Billing Address: ______________________________________________________________________

Policy Holder.s Name: _______________________________________________________________

Address: ______________________________________________________________________

Relationship to child/children: _________________________________________________________

ID #: ________________________________ Group/Policy #: ________________________

Secondary Insurance Company: ______________________________________________________

Phone #s: (________) ________ - _______________ (________) ________ - _______________

Billing Address: ______________________________________________________________________

Policy Holder.s Name: _______________________________________________________________

Address: ______________________________________________________________________

Relationship to child/children: _________________________________________________________

ID #: ________________________________ Group/Policy #: ________________________

Statement of Consent: (To be signed in the presence of a legalized notary public.)

In the event of an emergency or non-emergency situation requiring medical treatment, I, ____________________________,

hereby grant permission for any and all medical and/or dental attention to be administered to my child/children, in the event

of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the

administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recom-

mendation of qualified medical personnel.

Signature: _____________________________________________ Date: _____________________

Notarization:

On this ________ day of _______________, ________, ______________________________________

(date) (month) (year) (name of parent)

personally appeared before me in __________________ County (in the state of __________________)

and, in my presence, signed this medical release form.

Name of Notary Official: ______________________________________

Signature: _________________________________________________

Commission Expires: _________________________________________

Medical Release Form

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