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Troy band

TROY BAND
Student Medical and Treatment Authorization Form
Student’s Name_____________________________________________Age________________ (first) (last) (m.i.) Birthdate__________________________________Male________Female__________________ Home Address__________________________________________________________________ City_____________________________________________State__________Zip Code________ Home Phone Number____________________________________________________________ Mother/Guardian________________________________________________________________ Work Phone_____________________________________ Cell Phone______________________________________ Pager Number___________________________________ Father/Guardian________________________________________________________________ Work Phone_____________________________________ Cell Phone______________________________________ Page Number____________________________________
Name of Emergency Contact OTHER THAN PARTENT:______________________________
Relationship to student_____________________________ Phone Number____________________________________
Name of Secondary Emergency Contact OTHER THAN PARENT:______________________
Relationship to student_____________________________ Phone Number____________________________________
Family Doctor____________________________ Office Phone__________________________
Family Dentist____________________________ Office Phone__________________________
Orthodontist______________________________ Office Phone__________________________
Health Insurance Carrier________________________________________________________
Policy/ID #_______________________________ Policy/Plan#___________________________
Policy Holder’s Name____________________________________________________________
Health Insurance Phone #_________________________________________________________
Do any pre-certification, notification, or other requirements exist with respect to the health
insurance of the student? If so specify:______________________________________________
______________________________________________________________________________
Current Medications: __________________________________________________________
______________________________________________________________________________
General: Does student have: ( if “yes” explain)
___Yes ___No Allergies (i.e. food, drug)?___________________________________________
___Yes ___No Asthma?_________________________________________________________
___Yes ___No Heart Condition?___________________________________________________
___Yes ___No Diabetic?_________________________________________________________
___Yes ___No Vision Impairment?_________________________________________________
___Yes ___No Hearing Impairment?________________________________________________
___Yes ___No Other?____________________________________________________________
Is student subject to: (if “yes” explain)
___Yes ___No Headaches(especially migraines)?_____________________________________
___Yes ___No Seizures?________________________________________________________
___Yes ___No Motion Sickness?__________________________________________________
___Yes ___No Fainting? ________________________________________________________
___Yes ___No Sleep Walking? ___________________________________________________
___Yes ___No Upset Stomach?___________________________________________________
___Yes ___No Other?___________________________________________________________
Does student have a reaction to: (if “yes” explain)
___Yes ___No Bee Stings? ______________________________________________________
___Yes ___No Penicilin?________________________________________________________
___Yes ___No Other Drugs?_____________________________________________________
___Yes ___No Other?___________________________________________________________
___Yes ___No Has the student had any serious illness or surgery within the past ten years?
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ___Yes ___No Are any drugs ineffective in treatment?_________________________________
___Yes ___No Does the student wear contact lenses?__________________________________
Date of last tetanus shot: ________________________________________________________
Routine Medications needed daily_________________________________________________
______________________________________________________________________________

Student Name:________________________________________________________________
(First) (Last) (M.I)
___Yes ___No Can your student be given over the counter medications such as:
Tylenol, Imodium AD, Tums, etc….for normal ache and pains?
(Parent/Guardian Signature) Date Relationship to student ____________________________________ Does your child have your permission to swim? ___Yes ___No

Source: http://www.troybandboosters.org/yahoo_site_admin/assets/docs/TRIPMEDICALINFORMATION.327112618.pdf

Hygiene

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Microsoft word - cv dr banu english 03.02.2011.doc

Eugeniu BANU, MD. BOARD CERTIFICATIONS 2010 Inscription to the UK General Medical Council (ongoing application) Inscription to the French Medical Council, city of Paris (license 75.73889, RPPS number: 10004405956) Inscription to the Romanian Medical Council (license CJ-1228) Authorization procedure of the medical profession in France Board Certified Medical Oncologist (license 1578

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