Skip to content

Medical Referral Form

208 Reads

0 Comments

DUBLIN CITY SCHOOLS ATHLETE HEALTHCARE

MEDICAL REFERRAL FORM

Dear Physician,

Please complete the following information and fax it back to the above fax number or return it with the athlete after the visit to your office. This athlete will not be able to return to activity without clearance from you on this form. If we can be of any assistance, please feel free to contact us. Thank you for your time, consideration and cooperation.

*****************************************************************************************************

Name ______________________________________________Sport _______________

Injury _____________________________________________ Date ________________

DIAGNOSIS:_____________________________________________________________

X­Ray/Lab findings: ________________________________________________________

RECOMMENDATIONS:

___No Practice
     ___No Practice Until: _________________________

___CV Conditioning only: ___Ex. Bike ___UBE 

Practice­ but no Contact until: __________________

Limited Participation:_____________________

Full Participation:_____________________________

OTHER: _____________________________

Return Office visit on: ____________________

PHYSICIAN SIGNATURE / STAMP:                                                                                                       

 ATHLETIC TRAINING SERVICES

___ Ice
___ Contrast
___ Moist Heat
___Whirlpool Warm Cold___Modalities PRN
___

Exercise: ___________________

FREQUENCY

___Daily ___3 x Week ___PRN

____ # Weeks ____# Weeks ____# Weeks

DATE: ________________________________

  • Latest Photo Galleries

    View More Galleries

  • SUPPORT OUR SPONSORS

  • FOLLOW US ON TWITTER

    New Story: Event Recap: Week of July 15 – July 21 coffmanathletics.net/2017/07/…

    About 3 hours ago · reply · retweet · favorite

  • LIKE US ON FACEBOOK

  • SUPPORT OUR SPONSORS