Name of Authorized Person or Physician

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

Medical Insurance Information

Insurance Policy Number

Medical Allergies

Please enter the brand or generic name of medicine

Food Allergies

Please enter the type of food the patient is allergic to

Other Allergies

Please provide information as to other allergies the patient has

Any condition the patient may have and currently receiving treatment

Any other medical condition the patient has

Authorized Procedure

first aid summon a physician specialized in the field needed give authorization for the necessary procedures such as X-Ray, CT Scan, medication any hospital care necessary such as transport to another hospital with required medical facility as advised blood transfusion

I hereby declare that I have full custody of the aforementioned child/patient herein. I give authorization for the first aid treatment and other medical treatments as selected above. I agree that I shall assume all financial responsibility for the expenses as result from the treatment and care.

Signature of Parent/Guardian

Clear

Date Signed

Date

Medical Treatment Authorization Form