Medical Information Form

Personal Information

Emergency Contact

Insurance Information

Health Information

Consent and Authorization (for medical, hospital and/or dental services)

The undersigned, on behalf of himself, or minor if applicable, hereby authorizes and consents to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, to be rendered under the general or special supervision and upon advice of a physician and surgeon licensed in the State of Oregon, Washington, or California where applicable, and does also hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, to be rendered by a licensed dentist in the State of Oregon, Washington, or California where applicable. I hereby confirm consent, and agree to the foregoing.

GRANDPRIX

Lorem ipsum dolor sit amet, qui aperiam vituperatoribus at. Aliquip percipit ei vix, ceteros mentitum reprehendunt eu est.

instagram

QUICK INFO

Monday-Friday: 9am to 5pm; Satuday: 10am to 2pm
7300-7398 Colonial Rd, Brooklyn 242 Wythe Ave #4, Brooklyn
+ (123) 124-567-8901 + (123) 124-567-8901
[email protected] [email protected]