Patient Information First Name Last Name Age Date of Birth Gender Email Phone Number Street Address Street Address 2 City State/Province Postal/Zip Code Health Insurance Name Insurance Policy ID Insurance Package/Type Parent/Guardian or Emergency Contact Details Contact Person First Name Family Name Primary Phone Number Secondary Phone Number Medical Data Blood Type A B AB O Are you wearing glasses or contact lenses? Yes No Are you vaccinated? If yes, please list the vaccines you have received. Do you have any known allergies? If yes, then please specify below. Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them. What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.? Acknowledgment, Authorization and Waiver I authorize [Hospital] to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent. I confirm that the doctors explained the procedure thoroughly to me and how it will help me with my current condition. I authorize the use of anesthesia and understands the side effects I can experience from it. I authorize blood transfusion for emergency purposes. I grasp the risks and complications of not adhering to post-procedure instructions, including follow-ups. I understand that I am not allowed to eat or drink 4-6 hours before the procedure. I acknowledge that all information I provided int his form is true and accurate. ; Patient/Parent/Guardian Name Date Signed