Fill and Sign the San Francisco Sf Dph Form

© 2017 - Cottonwood Equestrian Publications AUTHORIZATION TO OBTAIN MEDICAL TREATMENT FOR MINOR CHILD WITNESS THIS AGREEMENT AND AUTHORIZATION by and between FARM NAME, hereinafter referred to as "Management," and ________________________________, hereinafter referred to as "Parent."Management is hereby authorized to obtain any and all medical treatment Management deems reasonably necessary for my minor child and/or children.Parent or guardian agrees to bear any cost connected therewith and shall pay promptly upon billing by the health care provider. Management shall incur no financial liability for medical treatment obtained pursuant to this authorization. Name(s) of child(ren)Social Security No.Health Insurance Carrier:Plan or Identification No.Primary Healthcare Provider Signature of Parent or GuardianTHE STATE OF ALABAMA ______________________COUNTYI, a Notary Public, hereby certify that _______________________________________ whose name is signed to the foregoing instrument or conveyance, and who is known to me, acknowledged before me on this day that, being informed of the contents of the conveyance, he/she/they executed the same voluntarily on the day the same bears date. Given under my hand this _____________ day of _____________, A. D. 20____. ____________________________________Notary Public © 2017 - Cottonwood Equestrian PublicationsPrint Name __________________________My commission expires:__________________