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Emergency Medical Treatment Release Form-Religious Education

Name of Minor
Message To Whom it may concern: As parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition, which in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
Name
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Relationship to you
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Address
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E-mail
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Emergency Phone --
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Family Physician
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Physician's Address
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Physician's Phone --
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List Allergies, Medications, Contract or other Pertinent Information
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Health Insurance Data
Company
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Policy
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Group
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Contract
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Signature
Message I authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the Physician/health care facility. This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. By typing your name here, you are signing this form electronically, which is the same as your signature on this form.
Date //
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Signed
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