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As the parent/guardian of _______________________________________________, I request that in my absence the above player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.
Birth Date of Player_____/_____/_____ Date of last Tetanus Booster_____/_____/_____ Known allergies of this player, including allergies to medicine_____________________________________ _______________________________________________________________________________________ Any other medical problems which should be noted_____________________________________________ _______________________________________________________________________________________ Family Physician_________________________________ Phone #_________________________________ Insurance Carrier__________________________________ Policy Number__________________________ Name of Parent/Guardian__________________________________________________________________ Address________________________________________________________________________________ City/State/Zip___________________________________________________________________________ Home Phone____________________ Work Phone__________________ FAX________________________ Person responsible for charges (if different than above)_________________________________________ Address________________________________________________________________________________ City/State/Zip___________________________________________________________________________ Home Phone____________________ Work Phone__________________ FAX________________________ Person to notify if parent/guardian is unavailable_______________________________________________ Home Phone____________________ Work Phone__________________
FAX________________________ Signature of Parent/Guardian_______________________________________________________________ |
