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AUTHORIZATION FOR TEMPORARY …

AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR. Child Full Legal Name: _____. Date of Birth: _____ Age: _____ Gender: _____. Doctor's Information Doctor's Name: _____. Doctor's Address: _____. Doctor's Office Phone: _____ Doctor's Emergency Phone: _____. Medical Insurer/Health Plan: _____ Policy #: _____. Allergies to Medications: _____. Allergies (Other): _____. If applicable, please note the conditions for which the child is currently receiving treatment: _____. Note any other significant medical information: _____. _____. Dentist's Information Dentist's Name: _____. Dentist's Address: _____. Dentist's Office Phone: _____ Dentist's Emergency Phone: _____. Dentist's Insurer/Health Plan: _____ Policy #: _____. Parent(s)/Legal Guardian(s): Parent #1: Name: _____. Address: _____. Home phone: _____ Work phone: _____. Cell phone: _____ Pager: _____.

supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in …

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