Medical Release *
I hereby consent, during my absence, for all medical and/or surgical treatment and/or special procedures which may be required during our absence,. Without in any manner limiting the foregoing appointment and authorization, if circumstances permit, I would like to have our doctor (stated below) consulted in connection with such medical and/ or surgical treatment and/or special procedures.
Emergency's Contact Name *
Emergency's Contact Name
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
Physician's Name *
Physician's Name
Physician's Phone Number *
Physician's Phone Number
Please list any conditions of which we should be aware: