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9-09 Previous editions 3-08 10-07 1-06 may be used. I give permission to licensed by the Department of Human Services Provider s Name to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care. Signature of Parent or Guardian Date Signed Name of Child s Physician or Health Clinic Physician s or Health Clinic s Phone Number Address of Child s Physician or Health Clinic Name of Health Insurance Carrier Hospital Preferred for Emergency Treatment H ...

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