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    Health Insurance Information and Release
    By my indication below, I consent to any ex-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care under the general supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As parent or legal guardian, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and no other consent is required by law. I hereby give permission to the physician selected by the activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist. I will assume FULL FINANCIAL RESPONSIBILITY for care given.
    I warrant and represent that I am eighteen years of age or over, and am fully aware of and understand the terms and legal consequences of the signing of this form. I intend my initials below to be a complete and unconditional release of all liability to the greatest extent allowed by law.

First Lutheran Church


1000 3rd Ave. SE, Cedar Rapids, IA  |  319.365.1494  |  info@firstlutherancr.org  |  A congregation of the ELCA

Office Hours: Mon. -Thurs. 8 a.m. - 5 p.m. ;  Fri. 8 a.m. - 4 p.m.

© 2020 First Lutheran Church; and God.
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