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Release Of Hospital & Physician
We, (names) and (names), of (complete address), request that (name of physician), the attending physician, and (name of hospital), located at (address), permit our son, (name), born (date), to be circumcised by (name of person to perform circumcision), whom we have selected as a person qualified in the ritual of our faith and by experience to perform this procedure. We assume full responsibility for the performance of this procedure on our son, (name), and hereby release (attending physician) and (name of hospital), its staff and any and all other persons, firms, partnerships and corporations that are or might be claimed to be liable, from all claims of whatever nature, known or unknown, including, without limitation, claims for personal injury and disability, pain, suffering, and mental anguish that may arise from the performance of the above-described procedure.
Dated: (date), at (time).
Executed in the presence of:
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]