Transcription of USA Hockey Consent to Treat
{{id}} {{{paragraph}}}
Example: air traffic controller
USA Hockey Consent to Treat
3Ca Rev 2/16 EMERGENCY CONTACTName: _____ Phone: (_____)_____Address: _____City: _____ State: _____ Zip Code: _____Physician s Name: _____ Phone: (_____)_____Hospital of Choice: _____COMPLETION OF MEDICAL history INFORMATION BELOW IS OPTIONALMEDICAL HISTORYIf the answer to any of the following questions is yes, please describe the problem and its implications for proper first aid treatment on the back of this Head Injury(concussion, skull fracture)q Fainting spellsq Convulsions/epilepsyq Neck or back injuryq Asthmaq High blood pressureq Kidney problemsq Herniaq Heart murmurq Allergies _____q Diabetesq Other _____ _____ _____Have you had (or do you currently have) any of the following?
USA Hockey National Championships Consent To Treat/Medical History Form This is to certify that on this date, I _____, as parent or guardian of _____, (athlete participant), or for myself as an adult participant, give my consent to USA Hockey and its medical representative to obtain medical ...
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: