Practical medical trials have confirmed the maximum effect of Levitra, whith a positive effect being observed in 99 of 100 patients kamagra uk Our internet store sells medicines produced in Indian pharmaceutical factories under licensed agreement.

Medical form sept 27 2012

MPSMA—MEDICAL RELEASE/INFORMATION FORM TODAY’S DATE:______________________________

Participant’s Name: _________________________________________ Date of Birth:____________________________
Street Address: _____________________________________________________________________________________
City:_________________________________________ State:______________ Zip Code_________________________
Emergency Contact #1_________________________________________________________________________

Relationship
Phone (please designate if cell, work or home)

Emergency Contact #2_______________________________________________________________________________

Relationship
Phone (please designate if cell, work or home)
Pertinent Past Medical History (including past hospitalizations & surgeries). (Use reverse side if needed).:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Currently under the care of a physician for:
_______________________________________________________________________________________________________________
I give my permission for my son/daughter to take or be given the following over the counter medication (OTC): (Please circle all that apply)
Advil/Motrin
Pepto Bismol
Imodium A-D
Benadryl
Cough Drops

Other over the counter medication and/or Herbal Medication: Please List:________________________________________________
Food & Drug Allergies (if more space is needed, please use reverse side):

__________________________________________________ ______________________________________________________ __________________________________________________ ______________________________________________________ Medications my son/daughter is currently taking. Include all over the counter & Prescription medication taken regularly (use reverse side if needed).
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
My son/daughter has my permission to carry his/her own Inhalers or Epi-Pen (please check if you approve)
PRIMARY INSURANCE: Policy #: ________________ Group #:_________________________ ID#: ________________
Name & Address of Insurance Company: ___________________________________________________________________ dental insurer, please put
Phone # :___________________________________Policy Holder (Employer):_____________________________________ and include copies of the
Employee’s Name:____________________________Relationship to student: ______________________________________
In the event of an emergency or non-emergency requiring medical treatment, I _________________________________________________, hereby grant permission for any and all medical and/or dental attention to be administered to my child,________________________________ in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Parent/Guardian’s Name (SIGNATURE): ______________________________________________________ Date: ____________________ Parent/Guardian’s Name (PRINT): _____________________________________________________________________________________ Phone numbers: Cell_____________________________; Home;_____________________________; Work: __________________________

Source: http://mpsmusic.org/index_files/MedicalForm2012.pdf