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Get University of Michigan POD-0053 2005-2021

of Minor: Name REG No. Date of Birth: (dd/mm/yyyy) Known Allergies/Drug Sensitivities: Known Medical Conditions: Any Limitations to Delegation: HMO/Insurance/Health Benefits and Physician Information: Company/Government Program Name: Member I.D.: Minor’s Physician Name: Phone: Minor’s Dentist Name: Phone: I/we are the parent(s) or legal guardian(s) of the above named minor. We appoint (in order of appearance): Name: Phone: Address: DL or State ID #: Name: Phone: Address: D.

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