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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?Have you had a recent tetanus booster? q Yes q No If yes, when? _____Are you currently taking any medications?

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 ...

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Transcription of USA Hockey Consent to Treat

1 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?Have you had a recent tetanus booster? q Yes q No If yes, when? _____Are you currently taking any medications?

2 Q Yes q No If yes, please list all medications on a doctor placed any restrictions on your activity? q Yes q No If yes, please explain on Hockey National ChampionshipsConsent To Treat /Medical History FormThis 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 care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury that could arise from participation in USA Hockey sanctioned said participant is covered by any insurance company, please complete the following:Insurance Company: _____Policy Number: _____Parent/Guardian/Adult Participant Signature: _____ Date: _____Excess accident insurance up to $50,000, subject to deductibles, exclusions and certain limitations, is provided to all USA Hockey registered team participants.

3 For further details visit or contact USA Hockey at (719) 576-USAH.


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