Medical Release Form (Page 2 of 3) in pdf

MEDICAL RELEASE FORM

Or 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 #: ______________________________

MEDICAL RELEASE FORM

Medical Release Form Page 2