Patient Medical Information Form

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Medical Information Form
Full Legal Name: ____________________________________________________________________________
Street Address: _________________________________City: __________________State: ________________
Zip Code: _____________
Social Security Number: (Required for treatment at most hospitals) __________________________________
Date of Birth: _____________________ Age__________________ Grade: ____________________________
List all Allergies or medical conditions that would impact treatment:
__________________________________________________________________________________________
__________________________________________________________________
Medications taken on a regular basis: ___________________________________________________________
Name of Parents or Legal Guardian: ____________________________________________________________
Street Address: _______________________________City: _____________________State: _______________
Zip Code: _______________
Home Phone: ____________________________ Business Phone: ________________________
Cell Phone: ____________________________
List Two Other Emergency Contacts
1) Name & Phone Number: ______________________________________________________________
2) Name & Phone Number: ______________________________________________________________
Name of Primary Insurance Policy Owner: ______________________________________________________
Insurance Company & Address: ______________________________________________________________
Policy Number: _________________________________________
Secondary Insurance Policy Owner: ___________________________________________________________
Insurance Company & Address: ______________________________________________________________
Policy Number: _________________________________________
I hereby give permission for authorized personal of (School Name) ___________________ to grant permission
for medical treatment for my child, (Child’s Name) ____________________, if I am not readily available, and I
authorize the physician and such other health care provider selected by (School Name) _________________to
render such emergency medical treatment as deemed necessary under the circumstances.
Parent or Legal Guardian: ________________________________________
Print Name: _________________________________ Signature: _________________________________
Date: ____________________________________

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