| MEDICAL INFORMATION FORM FRUITFUL HARVEST MISSIONS P.O. BOX 1130 SULPHUR SPRINGS, TX 75483 (903) 885-1424 NAME_____________________________________DATE OF BIRTH_______________ ADDRESS_________________________________________________________________ TELEPHONE______________________________________________________________ MEDICARE #______________________________________________________________ MEDICAID #_______________________________________________________________ OTHER INSURANCE: POLICY #_____________________________________________ COMPANY__________________________________GROUP_______________________ SOMEONE TO NOTIFY IN CASE OF EMERGENCY NAME____________________________________________________________________ RELATIONSHIP TO ABOVE NAMED PERSON._______________________________ DAYTIME PHONE ( )____________________NIGHT PHONE ( )_________________ BENEFICIARY_____________________________________________________________ MEDICAL HISTORY________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ALLERGIES_________________________________________________________________ BLOOD TYPE____________________________________________DON'T KNOW_______ MEDICATIONS NOW TAKING_________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ YOUR FAMILY DOCTOR______________________________________________________ NAME OF CLINIC OR OFFICE_________________________________________________ TELEPHONE ( )____________________________________________________________ I HEREBY AUTHORIZE RELEASE OF THIS INFORMATION TO ANY PHYSICIAN, HOSPITAL OR CLINIC AS NEEDED FOR MY MEDICAL CARE. SIGNATURE________________________________________DATE____________________ |