Texas Medical Release Form For Minor Child - Free Download
This form is provided by Texas Baha'i School for the medical care of the minor child attending school.
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Texas Medical Release Form For Minor Child
Texas Medical Release Form For Minor Child
TEXAS BAHA’I SCHOOL
MEDICAL RELEASE FORM
I, the undersigned parent or guardian of ___________________________, a minor, do hereby authorize Texas Bahá’í
School, or its designated representative, agent(s) for the undersigned, to consent to any x-ray examination, anesthetic,
medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the
general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act
on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said
physician or at said hospital. As the parent/guardian of a minor under the age of 18, I understand that this authorization
enables Texas Bahá’í School to arrange medical care for my dependant minor in the event I am unavailable.
I understand that I am responsible for payment of any and all medical expenses incurred on behalf of my dependent
minor. This authorization shall remain effective from September 21, 2012 to September 23, 2012, when my child is
attending the Texas Bahá’í School.
Parent/Guardian Signature: _____________________________________________ Date:__________________
Emergency Contact Name: ______________________________________________
Telephone: (_______) ___________________________
Family Physician Name: _____________________________________________
Telephone: (_______) __________________________
Medical Insurance Company: _____________________________________________________
Policy Number: ___________________________
Additional Emergency Contact (in the event parent cannot be reached): ___________________
Telephone: (_______) __________________________
Please list allergies, handicaps, limiting health conditions, medications, reactions to medications:
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