Appointment Of Short-Term Guardian For Minor Child(Ren) And Durable Healthcare Power Of Attorney Page 7

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ADDITIONAL INFORMATION
Child:
Nickname(s):
Date of birth ___/___/___ and last Tetanus Booster ___/___/___ for the above named child.
The following is a list of known allergies and allergies to medications of the above named child:
The above named child has the following known medical conditions or problems:
The above named child is currently prescribed the following prescriptions medications at the following frequencies
and other instructions:
Family Physician:
Phone Number:
Names of Parents/Guardians:
Address:
City/State/Zip:
Phone: (H)
; (W)
; (Other)
Person Responsible for charges:
Address:
City/State/Zip:
Phone: (H)
; (W)
; (Other)
Other Person to notify if parent/guardian is unavailable:
Phone: (H)
; (W)
; (Other)
Insurance Company:
Policy or Group Number:
Signature of Financial Guarantor (required if different from parent/guardian):
Date:
Print and complete one sheet per child
Page 7 of 8

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