Blank Medical Release Form

July 8, 2011

Blank Medical Release forms are used to give general information to medical facilities and used to authorize the physicians and facility to treat the mentioned person in whichever way seems necessary including taking blood and tissue samples. It is usually signed by a parent or guardian. A Sample Blank Medical Release Form is below.

Sample Blank Medical Release Form

As the Parent/legal guardian of ______________________________________ (Player) I request that in my absence the above named person be admitted to any medical facility for treatment as may be required. I request and authorize the facility and its licensed medical staff to conduct procedure and offer medical attention as may be necessary and the disposal of any specimen taken.

Date of birth (Player): __________________ Date of last Tetanus Booster: _______

Allergies: _________________________________________

Other Medical Conditions: ______________________________________________

Family Physician__________________________ Phone ______________________

Name of Parent/Guardian _______________________________________________

Address __________________________________________

Phone________________ Home______________ Work ___________________Fax

Person responsible for charges (if different from above)_______________________

Address__________________________Phone________________

Person to notify if parent/ guardian are not available__________________________

Address______________________________ Phone _________________________

Insurance Company and Policy Number____________________________________

Policy Holder _________________________________________

Signature of Parent/Legal guardian ____________________ Date ______________

Signature of authorizing body (sports, lawyer etc) _______________Date ________

 

Download Blank Medical Release Form in Word Format

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