Medical Release Form

DELEGATION OF AUTHORITY TO CONSENT FOR HEALTH CARE


We, __ __________________________ __, delegate our authority to consent for the health care of our minor child, ______________________________, for a period of time when we will not be reasonably available to exercise our authority.

We delegate our authority for consent to ________________________________________________.

This authorization of consent is to be exercised in good faith and in the best interest of our minor child.

This authorization of consent becomes effective on the

______ day of __________, ______ and will continue until the _________ day of ____________, 20__.



Dated this _______ day of ___________________, 20 _____.



______ __________________________________________________ _________________, Appointers

X___________________________________________________

X ___________________________________________________

(Parent/Guardian signature)

Address ___________________________________________________
Phone ___________________________________________________

I declare that I am an adult at least eighteen (18) years of age and that at the request of the above named, I witness the signing of this document by the appointer on the date noted above.
___________________________________________________

(Please print)

X __________________________________________________
(Notary)

Address _____________________________________________________________________________

Phone ____________________________________________________________________________________

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++__________________________________________ ________

Family Physician_____________________________________

Phone_____________________________________________

Insurance Carrier____________________________________

Medical Insurance Subscriber ID / Group Number

__________________________________________________

Card Number

__________________________________________________

Member’s Name and date of Birth

__________________________________________________

Claim Address

__________________________________________________

__________________________________________________

__________________________________________________

MEDICAL HISTORY

Allergies, if any, including medication:

__________________________________________________

__________________________________________________

__________________________________________________

Chronic or existing diseases or medical problems (i.e.

Diabetes, epilepsy):

__________________________________________________

__________________________________________________

__________________________________________________

Medicines your child is taking now:

__________________________________________________

__________________________________________________

In an emergency, parents can be reached as follows:

_Home ______________________________¬______________

_Mother Work__ ____________________________________

_Father Work_______________________________________

_Mother Mobile _____________________________________

_Father Mobile______________________________________

__________________________________________________

__________________________________________________