MEDICAL AUTHORIZATION AND INFORMATION FORM
In case of an emergency, I understand that
reasonable effort will be made to contact me. If I cannot be reached, I
hereby give my permission to act on my behalf in seeking emergency treatment
for my child for ANY treatment deemed medically necessary by a licensed physician
or dentist. This authorization if for medical and dental care including
but not limited to, hospital tests, hospital care, radiology, anesthesia,
medical/surgical diagnosis or treatment, dental/surgical diagnosis or treatment,
and for the administration of any necessary drugs.
| Name: | Birth Date: |
| Address: | Home Phone: |
| Father's Work Phone: | |
| Mother's Work Phone: | |
| Additional Contact Person: | |
| Address: | Phone: |
| Doctor's Name: | Phone: |
| Dentist's Name: | Phone: |
| Preferred Hospital: | |
| Insurance Company: | |
| Policy/Group#: | Social Security: |
| Allergies: | |
| Medications: | |
| Additional Information: | |
| Last Tetanus Immunization: | Contact Lenses: [ ] Yes [ ] No |
| Signature: | Date: |
| (Parent/Guardian) | |
I (We) Understand that it is my (our) obligation
to update this form from time to time as the information may change.