Emergency medical treatment release form - St Perpetua Parish - stperpetuaparish 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Minor' in the designated field. This is essential for identifying the child who may require medical treatment.
3. Fill in your 'Relationship to you' to clarify your connection to the minor, ensuring that the physician understands who is authorizing treatment.
4. Specify the 'Reason for which release is intended.' This helps healthcare providers understand the context of potential medical needs.
5. Complete the 'Address of Minor' and 'City' fields to provide accurate contact information for emergencies.
6. List any 'Emergency Phone(s)' where you can be reached, ensuring prompt communication if necessary.
7. Enter details for 'Family Physician,' including their name and phone number, along with their address and city, facilitating quick access to your child's medical history.
8. In the section for allergies and medications, provide any relevant information that could impact treatment decisions.
9. Fill out the 'Health Insurance Data' section with your insurance company, policy number, group number, and contract details for billing purposes.
10. Finally, sign and date the form at the bottom as a confirmation of your authorization for medical treatment.

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