Emergency & Medical Information Medical Information Allergies Or

Transcription

Emergency & Medical Information Medical Information Allergies Or
Emergency & Medical Information
_________________________________________
Child’s Name
________________________________
Date of Birth
_____
Sex
_________________________________________
Parent’s/Guardian Name
____________________________________________
Parent’s/Guardian Name
(______)___________________________________
Contact Number
(______)_____________________________________
Contact Number
_________________________________________________________________________________________________
Child’s Home Address, City, State, Zip Code
Alternate Emergency Contact ________________________________________(_____)__________________________
Name & Phone Number
Medical Information
_______________________________________________
Physician’s Name
___________________________________________
Phone Number
_______________________________________________
Insurance Company
___________________________________________
Policy Number
________________________________
Last Tetanus Shot
__________________________
Blood Type
_______________________
Last Check Up
Allergies Or Special Health Considerations
Bee/Wasp Stings________
Food Allergy_________
Medication__________
List Medications:____________________________________________________________________________________
Other_____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures
as may be performed or prescribed by the attending physician and/or paramedics of my child and waive my right to
informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the
case of an emergency.
____________________________________________________
Parent’s/Guardian Signature
_______________________________________
Date:

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