MEDICAL AUTHORIZATION

Inclusion Connections, Inc.

MEDICAL AUTHORIZATION FORM

This release is valid for 1/1/2014 to 12/31/2014. A photo copy of this authorization shall be

deemed effective as if it were the original.

I hereby authorize Inclusion Connections to give consent for any and all necessary emergency

medical and first aid care for my child.

Name______________________________________________________________

Address____________________________________________________________

City___________________________________________State_____Zip________

Parent/Guardian Name_______________________________________________

Home Phone__________________________________

Cell Phone Mom______________________________ Dad_______________________________

Alternate Contact: Name________________________________ Phone____________________

Insurance Company_____________________________Policy#_________________

Family Doctor/Pediatrician:____________________________Phone_____________

Medical History: List any current medications/allergies/known medical problems,

etc. Are there symptoms we should be aware of concerning medication or condition?

____________________________________________________________________

Parent/Guardian Signature___________________________________Date________

Download

MEDICAL AUTHORIZATION

DOC: 32.5 KB, PDF: 40.8 KB (1 page)

4.3 (12 votes)

Related templates

Medical records request template letter

2 pages

Medical record amendment / correction form

2 pages

Physical exam template

2 pages

Request to disclose medical records template

1 page

Medical application for assistance form

2 pages

Mood chart template

2 pages

Mood chart template

1 page

Mood / activity management chart

2 pages

Daily mood chart

1 page

Daily mood chart template

1 page

Mood chart template

1 page

Chart of temperament traits / mood template

1 page

Medical records request form

1 page