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authorization for medical treatment letter

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					    MEDICAL TREATMENT AUTHORIZATION LETTER
TO WHOM IT MAY CONCERN:

As the parents of (name)                                                     , we authorize the bearer of this
letter to approve medical treatment for our son/daughter if it is required and we are unable to be reached.


                                    CONTACT INFORMATION
    Home Phone:

                                             Mother                                 Father
    Work Phone:
    Mobile Phone:
    Insurance Carrier
       & Policy Number


                                    CHILD’S PERSONAL INFORMATION
    Date of Birth:
    Blood Type:
    Known Allergies:
    Being Treated For
    These Chronic Conditions
    Pediatrician:
    Pediatrician Phone:



                                                Thank you,
                                                _________________________________________
                                                                                         Mother’s Signature
                                                _________________________________________
                                                                                         Father’s Signature


     Subscribed and sworn to before me this ______ day of ________________, 20____.

                           ___________________________________________                       Notary Public
                           __________________________________________                     County, Texas




     A Small World Babyproofing & Child Safety Consultants, a Division of Peanutt, Inc., 972-442-0454

				
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posted:7/22/2008
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