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Forms 1- 7 of 7 Available for 'Medical Consents & Releases'

Child's Medical Care Authorization  

I, ___, the _ (Father/Mother) of ______ (Child), who is at present in the custodial care of _____ (Name/Names) pending ___ (His/Her) formal adoption, do hereby lawfully authorize _______ (Name) to make any arrangements necessary for the appropriate medical or surgical care of the above-named child and confer all ...

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Authorization for Release of Records  

______ (Names and Mailing Addresses of Persons or Institutions Requesting Information). This medical information is to be limited to the following: __ ______ (Specify Such Information as Medical Condition or Injury; Treatment, Examination, or Hospitalization Received; and Dates of Treatment). The further use or disclosure of the authorized ...

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Release of Medical and Psychiatric Records  

I authorize you to release to the persons listed below information concerning the medical and psychiatric evaluation and treatment received by the above named patient at __ (name of hospital) during the approximate period from __ (month & day), ___ (year), to ___ (month & day), _ (year). (Director of Medical Records or the person authorized to release information or to supervise its release). I understand that

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Affidavit re Knowledge of Birth  

2. The person whose birth is being registered was born on __ (month & day) _ (year), at _____ (address). 5. I have firsthand and personal knowledge of the birth of the person whose birth is being registered as follows: ____. 6. I am _ (___) years of age, and I am related to the person whose birth is being registered as follows: ___ (exact relationship).

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Consent to Surgery and Release  

Consent and release executed by ____ (name), of ______ (address), as releasor, to _____ (hospital) located at ______ (address), its directors, medical and surgical staff, agents, employees and any other person connected with the surgery hereafter to be performed on releasor with _ (his or her) consent. 4. ...

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Release - Temporary Leave of Absence from Hospital or Medical Facility  

I, the above-named patient, having obtained permission from the attending physician to be absent from hospital for __ (Time Period of Absence), assume all responsibility for myself during this temporary absence and release __ (Name of Hospital), its personnel and attending physicians from all responsibility during this absence for my condition, including any deterioration of condition, accident, and any acts of omission or commission on my part that cause harm to ...

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Vaccination-Notice and Release  

___[company name] has arranged for nurses from the ___ Clinic to administer FREE flu shots on ___[date] from ___[start and end time]. Pregnant women also should not receive a flu shot. I have read the above notice dated ___ regarding the flu vaccination.

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