2024 Robie Pierce Regattas Medical & Emergency Information Form
Full Name
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First Name
Last Name
What is your Date of Birth?
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What is your gender?
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Please Select
Male
Female
N/A
Contact Number
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What is your blood type?
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What is your physical disability?
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Chronic Ailments - please check those that apply:
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Asthma, or other respiratory problems
Diabetes or hypoglycemia
Hemophilia or other bleeding problems
Epilepsy / seizure
Other
Are you currently taking any medication?
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Yes
No
Please list them.
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Do you have any medication allergies?
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Yes
No
Not Sure
Please list them.
*
Other Allergies - please check all that apply
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Bee Stings
Latex
None
Other
What is the name and contact information for your Physician?
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
What is the name and ID number of your Health Insurance Carrier?
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I do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or procedure rendered under the general or specific supervision of any member of the medical staff or of a dentist licensed under the provisions of the Stated Education Law and/or Public Health Law of the State and on the staff of any hospital holding a current operating certificate issued by the State Department of Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact my Emergency Contact prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if my Emergency Contact cannot be reached.
*
Please Select
I do authorize and consent to the provisions in the above paragraph.
I do NOT authorize or consent to the provisions in the above paragraph.
Submit
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