Health History Form (Page 5 of 5) in pdf

Health History Form Page 5

PERSONAL HEALTH INSURANCE FORM

Must be completed for ALL students.

INSURANCE INFORMATION:

Insured’s Name: ________________________________________________________________________

Policy Holder Name: ________________________________

Date of Birth: ____________________

Policy Holder Relationship to Insured: ______________________________________________________

Employer Name and Phone: _______________________________________________________________

Insurance Company Name: _______________________________________________________________

Insurance Address: ______________________________________________________________________

Insurance Phone Number: _________________________________

Please provide a copy of the front and back of your insurance and/or prescription benefit card(s).

Parental consent for minors under 18 years of age.

The law requires parental permission before medical or surgical treatment of a minor. The hospitals in

our area have a similar requirement relative to admission and treatment. If such treatment becomes necessary,

every effort will be made to obtain your specific consent before treatment. On occasion you may be unavailable.

In order to avoid unnecessary delay, your prior consent to treatment is important. However, no surgical procedures

will be performed without your specific knowledge and consent, except in cases of critical emergency.

I understand the considerations set forth above, consent to use of the above insurance policy and authorize any

physician and any hospital involved to perform such medical or surgical treatments as me be deemed necessary

for my son/daughter.

Signed: _________________________________________ Relationship to student: ____________________

Health History Form Page 5