Medical Release Form for a Minor

Medical Release Form for a Minor

Authorization for Treatment of Minors

Minor #1 Name

Date of Birth

Minor #2 Name

Date of Birth

Minor #3 Name

Date of Birth

Parent/Guardian's First Name

Parent/Guardian's Last Name

Address

City

State

Zip

Home Phone

Mobile

Business Phone

Insurance Provider

Policy Number

Notify in Emergency (if other than parent or guardian)

Relationship

Phone

Family Physician

Phone

Allergies

Last Tetanus

Medicines currently being used and their dosage/frequency

Current overal health

Authorization for Treatment of Minors

We, the undersigned, parent or legal guardian of these minors, do hereby consent authorized medical personnel to perform routine tests and treatment for the health of my children. In the event that we cannot be reached in an emergency, we hereby give permission for an authorized physician to hospitalize, secure proper treatments, and to order injection, anesthesia, or surgery for my children as named above.

* eSignature of Parent/Guardian

Date

Fri, April 26 2024 18 Nisan 5784

Monday - Thursday	9:00AM-5:00PM
Friday	9:00AM-3:00PM