(no subject)
Name of Minor: Andrea Koerber
Address: 17484 White Plains
Macomb, MI 48044
Father’s Name: John S. Koerber III
Home Phone: 586-228-2206
Work Phone: 586-909-4670
Mother’s Name: Tracy Sypniewski
Home Phone: 810-923-3313
Family Physician: St. Johns Pediatrics
Insurance Company: Blue Care Network of Michigan
Policy #:XYH920154446
Parent Authorization
By this signed medical release form I hereby authorize the emergency room staff and medical staff to treat my child, Andrea Koerber; as such treatment may be required from March 23, 2008 to March 29, 2008 while my child is in the care of Kelly Fobare due to my absence. I understand that if contact by the emergency staff to either parent or legal guardian is unsuccessful, that I am hereby giving permission and authorizing emergency treatment by any available medical care provider, and I agree to accept financial responsibility for any such care of treatment extended.
John S. Koerber III
Child’s Birth date: 05/02/90
Date of Last Tetanus: 03/10/08
Allergies to drugs or food: N/A
Address: 17484 White Plains
Macomb, MI 48044
Father’s Name: John S. Koerber III
Home Phone: 586-228-2206
Work Phone: 586-909-4670
Mother’s Name: Tracy Sypniewski
Home Phone: 810-923-3313
Family Physician: St. Johns Pediatrics
Insurance Company: Blue Care Network of Michigan
Policy #:XYH920154446
Parent Authorization
By this signed medical release form I hereby authorize the emergency room staff and medical staff to treat my child, Andrea Koerber; as such treatment may be required from March 23, 2008 to March 29, 2008 while my child is in the care of Kelly Fobare due to my absence. I understand that if contact by the emergency staff to either parent or legal guardian is unsuccessful, that I am hereby giving permission and authorizing emergency treatment by any available medical care provider, and I agree to accept financial responsibility for any such care of treatment extended.
John S. Koerber III
Child’s Birth date: 05/02/90
Date of Last Tetanus: 03/10/08
Allergies to drugs or food: N/A