Child’s Grade _______

MEDICAL TREATMENT RELEASE FORM

To Whom It May Concern:

As a parent/ guardian, I do hereby authorize the treatment by a qualified and licensed physician

of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor: Relationship to you:

Address of Minor: City:

Emergency Phone(s): ( ) ( )

Family Physician: Phone:

Physician Address: City:

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

Health Insurance Data:

Company: Policy:

Group: Contract:

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

of Notice 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:

(Parent or Guardian)