Medical Authorization Release Form
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3Medical Authorization Release Form
Form Expiration Date_________________
Personal Information
Last Name: ________________________________
First Name: ________________________________
Address: __________________________________________________________________________________
City: _______________________________
Zip Code:______________
Phone: (___) _______________
Date of Birth: _____/_____/______
Age:________
Father’s Name: _____________________________________________________________________________
Employer: ___________________________________________________________________________
Business Phone: (___) _______________
Cell Phone: (___) _______________
Mother’s Name: ____________________________________________________________________________
Employer: ___________________________________________________________________________
Business Phone: (___) _______________
Cell Phone: (___) _______________
Medical Information
1. Emergency Contacts (In the event that a parent cannot be contacted.)
__________________________ Relationship: ______________________
Phone: (____) ____________
__________________________ Relationship: ______________________
Phone: (____) ____________
__________________________ Relationship: ______________________
Phone: (____) ____________
2. Family Physician ______________________________________________
Phone: (____) ____________
3. Hospitalization & Major Medical Insurance
Company Name: ___________________________________________
Policy #: ________________
Group Name or Number: _______________________________________________________________
Type of Coverage: ____ Major Medical
____ Hospitalization
____ Dental
____ Other: _____________________________________
4. Family Dentist ________________________________________________
Phone: (____) ____________
5. Known Allergies
Medication
Foods
Plants
Insects
____________________ _____________________
_________________
______________________
____________________ _____________________
_________________
______________________
____________________ _____________________
_________________
______________________
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Parent category: Business