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________________ Home Phone__________________ Work Phone_________________ FAX________________
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