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Get MI Saint Perpetua Parish Medical Treatment Release Form 2004-2024

Is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me. Name of Minor: Relationship to you: Reason for which release is intended: Address of Minor: City: Emergency Phone(s): Family Physician: Phone: Physician Address: City: List allergies, medication, contract, or other pertinent comments: Health Insurance Data: Company: Policy: Group: Contract: I further authorize the person who presents the minor to sign the Acknowl.

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