SANDITE BANDS MEDICAL RELEASE FORM
I (We) the undersigned Parent, Parents or Legal Guardian of the below named minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis and treatment and emergency hospital care which is deemed advisable by and is to be rendered under the general or specific supervision of any member of the medical staff and emergency room staff licensed under the provisions of the medicine practice act and the staff of any acute general hospital holding a current license to operate a hospital from said state.  It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of the best judgment may deem advisable.  It is understood that the effort shall be made to contact the undersigned prior to rending treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
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Email *
Minor's Name:  (First & Last)
Minor's Birthdate:
Home Phone Number (if Applicable): ( xxx) xxx-xxxx
Sex (Biological):
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Home Address:    (City & Zip on following questions...)
City, State:
Zip Code:
List any Restrictions...
Allergies to drugs or foods:  (Be Specific)
Special Medications or Pertinent Information:
Date of Last Tetanus Toxoid Booster:
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DD
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Father Name (First & Last):
Father Phone Number (Cell or Home): (xxx)xxx-xxxx
Father Work Phone Number: (xxx) xxx-xxxx
Mother Name ((First & Last):
Mother Phone Number (Cell or Home): (xxx)xxx-xxxx
Mother Work Phone Number: (xxx) xxx-xxxx
Insurance Company Name:
Insurance Policy Number:
Insurance Company Address:
Insurance Company City:
Insurance Company State, Zip:
Physician Name:
Physician Address:
Physician City:
Physician State, Zip:
Physician Phone Number: (xxx) xxx-xxxx
Financial Responsibility:  (Who will pay what insurance won't?)
Signature of Father or Legal Guardian:  (Your signature here and email timestamp will serve as an electronic signature for these purposes)
Father Signature Date:
MM
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DD
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YYYY
Signature of Mother or Legal Guardian:  (Your signature here and email timestamp will serve as an electronic signature for these purposes)
Mother Signature Date:
MM
/
DD
/
YYYY
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