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Unformatted text preview: The information on this form is confidential and will not be released outside the Health Service without authorization from the student. NAME________________________________________________________________________________________________________ L a s t F i r s t M i d d l e Birth date________/________/________ ___________________________________________________ Male______ Female______ State/Country of birth Permanent Address ___________________________________________________________________ Phone (_____)______________ Street Address City State Zip Parent, Guardian, or Emergency Contact: __________________________________________________________________________(_____)____________ (_____)___________ Name Address-if different than above Home Phone Work Phone __________________________________________________________________________(_____)____________ (_____)___________ Name Address-if different than above Home Phone Work Phone Personal Physician ____________________________________________________________________________ (_____)____________ Name Address Phone Student Health Services Miami University 421 South Campus Ave. Oxford, Ohio, 45056 513-529-3000 MEDICAL FORM The above is true to the best of my knowledge. PERMISSION is hereby granted to the Student Health Service staff to provide treatment/preventive care of this student. PERMISSION is also granted to the Student Health Service to refer this student to another duly licensed physician or surgeon when indicated....
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This note was uploaded on 02/01/2012 for the course CHEM 141 taught by Professor Crowder during the Fall '11 term at Miami University.
- Fall '11