Iowa Notarized Medical Release Form
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MEDICAL RELEASE FORM
As the parent/legal guardian of _______________________________, I request that in my absence the abovenamed player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize
physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such
licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative
procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of
examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken
from the above-named player.

Date of player's birth

Date of last tetanus booster
month

day

year

month

day

Known allergies of this player, including any allergies to medicine:

Any other medical problems which should be noted:

Family Physician

Phone

Parent/Guardian

Home Phone

Work/Cell
Phone
Parent/Guardian
Address

City