RELEASE FOR MEDICAL TREATMENT

RELEASE FOR MEDICAL TREATMENT
THE FOLLOWING INFORMATION MAY BE USED IN OBTAINING OR PROVIDING EMERGENCY MEDICAL TREATMENT:
Individual Physician:

First NameLast Name
Phone Number:

Area CodePhone Number
Location Of Medical Records:
Medical Assistance #:
Medical Insurance Company Name:
Medical Insurance Policy #:
Blood Type, If Known:
Allergies:
Other Medical Conditions:
Current Medications:
Other Pertinent Medical Information:
IN THE EVENT OF A MEDICAL EMERGENCY, please notify the following persons as soon as possible, preferably prior to the administration of emergency medical treatment:
Individual # 1:*

First NameLast Name
Relationship*
Home Telephone:*

Area CodePhone Number
Work Telephone:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Individual # 2:

First NameLast Name
Relationship
Home Telephone:

Area CodePhone Number
Work Telephone:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
THIS AUTHORIZATION, WHICH SHALL BE EFFECTIVE FOR ONE YEAR FROM THE DATE OF SIGNING, MAY BE REVOKED OR REVISED IN WRITING AT ANY TIME.
I authorized agents of CLAYS. to render first aid to me and/or secure emergency medical treatment on my behalf in the event they determine that my health, life and/or well-being are in immediate danger. In such an event, CLAYS agents are authorized to release any information to the medical authorities as may be required for my treatment.
SIGNATURE OF INDIVIDUAL:*

Clear
SIGNATURE OF PARENT/GUARDIAN (IF APPLICABLE):

Clear
DATE:*

MonthDayYear
Date
PRINT NAME AND RELATIONSHIP TO INDIVIDUAL:*
Should be Empty: