severe headaches / blisters / allergies / acne / warts / significant accidental injury / strain / chronic illness / itching / severe cramps / hernia / seizure / severe coughing / numbness / high cholesterol / ever experienced chest pain / injury / severe vital infection / high blood pressure / athletic injuries / serious illness / i.e. mononucleosis / wheezing / head injury / asthma / incurred injury / /
MedicalTreatment
IMMUNIZATION / major surgery / surgery / first aid / /
Organization
Dental Yes No Preferred Provider Organization / Point of Service / CIRCLE Health Maintenance Organization / U.S. Securities and Exchange Commission / /
CCBC ATHLETIC TRAINING – CATONSVILLE, DUNDALK, ESSEX[removed]ACADEMIC YEAR Authorization for the Release of Medical Records and Protected Health Information I, ___________________________________, hereby authorize an