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Iowa Notarized Medical Release Form

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Iowa Notarized Medical Release Form
Iowa Notarized 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
Insurance Carrier
State of County of
Sworn to and subscribed before me on the ___________ day of _____________________________, 20_______.
MEDICAL RELEASE FORM
NOTARIZATION
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
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
Notary public in and for the State of ____________ My commission expires _______________________
Work/Cell
Phone
Policy Number
Signature of
parent/guardian
Iowa Notarized Medical Release Form