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Iowa Medical Release Form

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Iowa Medical Release Form
Iowa Medical Release Form
month day year month day year
Known allergies of this player, including any allergies to medicine:
Any other medical problems which should be noted:
Family Physician Phone
Parent/Guardian Home Phone
Home Phone
Home Phone
Work/Cell
Phone
Policy Number
Signature of
parent/guardian
Insurance Carrier
Policy-holder's Name
City, State Zip
Person to notify if
parent/guardian
unavailable
As the parent/legal guardian of _______________________________, I request that in my absence the above-
named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize
physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such
licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative
procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of
examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken
from the above-named player.
Work/Cell
Phone
City, State Zip
Group Number
Carrier's Phone
Number
Date
MEDICAL RELEASE FORM
Person responsible for
charges address
Parent/Guardian
Address
Person responsible for
charges, if differs
Date of player's birth Date of last tetanus booster
Work/Cell
Phone
Iowa Medical Release Form