Blank Medical Release forms are used to give general information to medical facilities and used to authorize the physicians and facility to treat the mentioned person in whichever way seems necessary including taking blood and tissue samples. It is usually signed by a parent or guardian. A Sample Blank Medical Release Form is below.
Sample Blank Medical Release Form
As the Parent/legal guardian of ______________________________________ (Player) I request that in my absence the above named person be admitted to any medical facility for treatment as may be required. I request and authorize the facility and its licensed medical staff to conduct procedure and offer medical attention as may be necessary and the disposal of any specimen taken.
Date of birth (Player): __________________ Date of last Tetanus Booster: _______
Allergies: ___________________________________________________________
Other Medical Conditions: ______________________________________________
Family Physician__________________________ Phone ______________________
Name of Parent/Guardian _______________________________________________
Address _____________________________________________________________
Phone________________ Home______________ Work ___________________Fax
Person responsible for charges (if different from above)_______________________
Address_______________________________Phone_________________________
Person to notify if parent/ guardian are not available__________________________
Address______________________________ Phone _________________________
Insurance Company and Policy Number____________________________________
Policy Holder _________________________________________________________
Signature of Parent/Legal guardian ____________________ Date ______________
Signature of authorizing body (sports, lawyer etc) _______________Date ________
