Wildwood Chapel Medical Form

Wildwood Chapel

7296 T.H. 51 - Upper Sandusky, OH 43351

419-294-4610 wildwoodchapel@gmail.com

Medical Information and Emergency Release Form

In the unlikely event that a medical problem should arise we would like to have all of the relevant medical and health information on record. If this problem should be an emergency or you are for some reason unable to make decisions or sign documents for yourself, we need you to also give the Wildwood Chapel staff your permission to act in your behalf in the event of an emergency. Please carefully read and complete the following information and sign as needed.

Minor Name

Age

Birthdate

Date

Address

Street Address Line 2

CityState

Zip

Home Phone

Gender

MaleFemale

Please list and explain any special medical information, such as unusual medical conditions, allergies to medications or foods, current medications being used, unusual physical conditions, etc.

I do hereby give my permission for the personnel of Wildwood Chapel or their agents, to seek medical attention and treatment for me as needed. W.C.'s agent may act in my behalf to secure and approve any and all necessary medicine, treatment, surgery, or procedure deemed necessary by attending medical personnel. I understand that I and my personal insurance company are fully responsible and liable for any and all expenses incurred as a result of attaining and administering these services and treatments.

Signed

Date

Please type name

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Insurance Co Name

Policy Number

Please explain any information or instructions on how to activate your insurance policy in an emergency. Please also list any information you would like regarding special needs, additional phone numbers, family doctor's name and number, etc. on the back of this sheet. Thanks.