His Hill Medical Form
First Name: *
Your answer
Last Name: *
Your answer
Date of Birth: *
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Age: *
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Sex: *
Home Address: *
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City: *
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State/Prov: *
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Zip Code: *
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Country: *
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Emergency Contact Information
Parent/Guardian First & Last Name: *
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Cell Phone #: *
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Home Phone #:
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Work Phone #:
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Address (if different from above):
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Emergency Contact Name (if parent cannot be reached): *
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Phone #: *
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Insurance Carrier
Please complete the following insurance information below. Note: His Hill provides insurance as a secondary coverage.
Carrier Name: *
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Group #: *
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Member I.D. *
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Carrier Address: *
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Carrier Phone #: *
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Health History
Please check the following conditions if you have ever had them in the past or are presently being treated.
Please explain all checked responses:
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Immunization & Current Health Information
Date of most recent Tetanus booster shot:
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List any medications you are currently taking. If none, write "N/A" *
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Are you currently under any treatment for any condition whatsoever? If yes, please specify:
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List any dietary, physical, or other restrictions:
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Activity and Treatment Authorization
Please sign your name below authorizing your agreement of the following statements.
This health history is correct so far as I know, and I give my consent to engage in all school/camp/athletic activities, except as noted by me and my physican. I hereby give permission to the staff at His Hill to secure and administer medical treatment, as they deem appropriate, including hospitalization. I also give permission to the medical personnel selected by His Hill to order x-rays, routine tests and treatments. If hospitalized, I give permission for the His Hill staff to act on my behalf, and represent my family in their absence. *
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