Medical Information
EMERGENCY MEDICAL AUTHORIZATION
Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone number
Address *
In case of an emergency please notify,(name, relationship and phone number) *
Insurance (In case of medical treatment, and/or expense, your personal coverage will be the primary carrier.) Please list Primary Insurance Company name and policy #.
Health List Family Physician Name and Phone #:
Past Medical History(Please be brief. List any injuries, current medications etc.)
Any medication allergies or general allergies?
Last Tetanus vaccination or other vaccination dates:
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