Medical Treatment Release Form printable pdf download

Medical Treatment Release Form

MEDICAL TREATMENT RELEASE FORM

To Whom It May Concern:

As a parent/guardian I do hereby authorize the treatment by a qualified and licensed Medical Doctor in an

emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement,

physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has

been made to reach me.

Name of Minor:

Relationship to you:

Reason for which release is intended:

Address of Minor:

City:

State:

Zip:

Phone:

Emergency Phone:

Date of Birth:

Family Physician:

Address:

City:

State:

Zip:

Phone:

List allergies, medication, contacts, or other pertinent comments:

Allergies:

Medications:

Comments/Other:

Health Insurance Data:

Company:

Policy:

Group:

Contract:

I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice of Privacy

Rights that may be presented by the physician or health care facility.

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical

treatment deemed necessary and appropriate by the treating physician.

Date:

Signed:

Medical Treatment Release Form