CISA Clinic Student
Medical Release
Please print, fill out, sign and
return this form to:
Marylee Goyan
PO Box 180580
Coronado, CA 92178
Participant's Name: __________________________________________
Participant's E-Mail Address: ___________________________________
Family Physician: ____________________________________________
Address: __________________________________________________
City, State: ________________________________________________
Tel: (___)______________
Zip: ______________
Insurance Co.: ______________
Policy Number: ______________
Have you been treated for:
Rheumatic fever |
Heart disease |
Chronic disease of the lung |
Asthma |
Chronic ear disease |
Disease of the bones of joints |
Epilepsy |
Other: _____________________________ |
Any vision or hearing defect |
Do you wear contact lenses? |
Last Physical Examination: |
____________________________ |
I, the undersigned, do hereby authorize and consent to any
x-ray examination, anesthetic, medical or surgical diagnosis rendered
under the general or special supervision of any member of the medical
staff licensed under the provisions of the Medical Practice Act or a
dentist licensed under the provisions of the Dental Practice Act and on
the staff of any acute general hospital holding a current license to
operate a hospital from the State of California Department of Public
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 the
undersigned prior to rendering treatment to the patient, but that any of
the above treatment will not be withheld if the undersigned cannot be
reached.
Signed: ____________________________ Date: ______________________
(if over 21) Signature of Participant
(if under 21) Signature of Father, Mother or Guardian
In Case of Emergency, Please Notify:
Name: ____________________________ Tel: (___) ____________________
Name: ____________________________ Tel: (___) ____________________
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