EMERGENCY MEDICAL AUTHORIZATION
Date of Birth
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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