Christ The King Catholic Church

MAILING ADDRESS: P.O. Box 95, Acme, MI 49610

SITE/GPS: 3801 Shore Road, Williamsburg

EMAIL: generalmail@christkingchurch.org

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MEDICAL TREATMENT RELEASE FORM

- Faith Formation

The maximum number of form submissions has been reached. This form is currently not available.
- To Whom It May Concern:
  
  As a parent/guardian I do hereby authorize the treatment by a qualified and licensed Medical Docctor in an emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
- Name of Minor: Please enter valid data.
- Relationship to you: Please enter valid data.
- Reason for which release is intended: Please enter valid data.
- Address of Minor: Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Emergency Phone: Please enter valid data.
- Date of Birth: Please enter valid data.
- Family Physician: Please enter valid data.
- Address: Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- List allergies, medication, contacts, or other pertinent comments:
- Allergies:
- Medications:
- Comments/Other:
- Health Insurance Data:
- Company: Please enter valid data.
- Policy: Please enter valid data.
- Group: Please enter valid data.
- Contract: Please enter valid data.
- I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice of Privacy Rights that may be presented by the physician or health care facility.
- This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
- Date REQUIRED Please fill out this field. Please enter a date.
- Signed: REQUIRED Please fill out this field. Please enter valid data.
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