Warrior Sports Medicine

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Warrior Sports Medicine"

Transcription

1 Warrior Sports Medicine On behalf of Warrior Athletics we would like to welcome Student Athletes and their families to the Academic Year. Please take the time to read this information so that you will understand the objectives of the Warrior Sports Medicine Program. We begin by wishing our student athletes a safe and competitive upcoming season. Sincerely, Dake Walden Head Athletic Trainer Sports Medicine Team: CSU Stanislaus Athletics: Dake Walden, ATC CSU Stanislaus Athletics: Gary Hogan, ATC CSU Stanislaus Health Center: Dr. Sergio Mazon Dr. Scott Hennes Mission: To ensure that all student athletes at CSU Stanislaus and their visiting opponents have their athletic related injuries and illness cared for and managed for maximum potential to continue to play their sport, attend and pass classes and function long beyond the date of graduation. When Injuries and Illness occur: Athletes should report to the athletic training room immediately when injuries occur. A certified athletic trainer will evaluate most injuries first. Injuries within the scope of the staff will be treated in house. Injuries beyond the scope of staff will be referred to an appropriate licensed medical physician and a treatment plan will be developed. Athletes who sustain injuries beyond the scope of the Warrior Sports Medicine Staff will be referred to a physician. Physician referrals are dependent on factors such as severity and primary care insurance. The Student Health Center on Campus provides many services that are paid by students tuition. Students may pay small fees for lab work and prescription medications. When student athletes are referred for services off campus, the Warrior Sports Medicine Staff must make every effort to utilize the Student Athlete s primary care insurance first. Please read and completely fill out the forms that follow this page. These forms must be completed annually. Incomplete forms will be returned. Please mail, FAX, or completed forms to: Dake Walden Head Athletic Trainer California State University Stanislaus Dept. of Athletics One University Circle Turlock, CA Phone: (209) FAX: (209) All forms are due by July 15, 2013 ONE UNIVERSITY CIRCLE TURLOCK, CALIFORNIA PHONE (209) FAX (209) THE CALIFORNIA STATE UNIVERSITY Bakersfield Channel Islands Chico Dominguez Hills East Bay Fresno Fullerton Humboldt Long Beach Los Angeles Maritime Academy Monterey Bay Northridge Pomona Sacramento San Bernardino San Diego San Francisco San Jose San Luis Obispo San Marcos Sonoma Stanislaus

2 CSU-STANISLAUS MEDICAL HISTORY /QUESTIONNAIRE NAME: BIRTHDATE: SSN: SPORT CHECK THOSE ILLNESSES/INJURIES YOU HAVE HAD OR HAVE NOW MEDICAL HISTORY: Yes No Diabetes Epilepsy Headaches Asthma Mononucleosis Convulsions Heart Problems Hypertension Kidney Problems Bronchitis/Chronic cough Concussion(s) Heat Illness/Syndromes Currents Illness/Injuries ORTHOPEDIC HISTORY: Yes No Ankle Injuries Any Bone Fractures Any Surgeries Elbow Injuries Foot Injuries Hand Injuries Knee Injuries Rib Injuries Shoulder Injuries Spine/Back IF YOU ANSWERED, YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN IN DETAIL BELOW: PLEASE CHECK BELOW IF YOU HAVE ANY OF THESE ALLERGIES OR LIST ANY THAT MAY NOT APPEAR BLOW: Bee Stings: Please Specify or list any allergies that you have or do not appear at the left: Poison Ivy/Oak: Hay Fever: Adhesive Tape: Foods: Medications: Assumption of Risk Participation in sports/athletics requires an acceptance of risk of injuries. Athletes assume that those who are responsible for the supervision of the sport have taken reasonable precautions to minimize such risks. However, every sport contains inherent risks and the possibility of injury is present, regardless of precautions. I understand that the dangers and risks of playing and/or practicing intercollegiate sports/athletics include but are not limited to: death, serious head and spine injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, and all aspects of musculoskeletal systems, and serious injury or impairments to other aspects of my body and general health and well-being. I understand and assume the risks and dangers associated with participation in intercollegiate athletics at California State University, Stanislaus Athlete Signature

3 Warrior Athletic Insurance Information The following explains the policies and procedures regarding the California State University Risk Management Authority Athletic Injury Medical Expense Program(CSURMA AIME). Please read and understand before signing the bottom line then precede to the next page. CSURMA AIME, California State University, Stanislaus Athletic Injury Secondary Insurance Policy The insurance provided by the AIME is SECONDARY. Student Athletes must file all claims with his/her parent s/spouse s/own primary care insurance BEFORE the AIME policy can be utilized. If an athlete does not have primary care insurance then the athletic departments secondary insurance becomes primary for athletic related injury and illness only. Primary care student insurance is available for purchase through the university s Student Health Center. It is highly recommended that student athletes be in possession of their primary insurance cards. The athletic department s athletic insurance only cover athletic participation related injury and illness. It does not cover the following: Expenses for injuries that occur outside the university s athletic participation (This includes open gym, captain s practice, and other activity not supervised by the coaches). An athlete s pre-existing injury or illness (This includes chronic illness). Injury and illness related to body piercing, tattoos, banned substances and intoxication. Treatments and visits not authorized by the Head Athletic Trainer. Alternative treatment such as Chiropractors and Acupuncture. Expenses for the treatment of sickness or disease in any form. Expenses for lost of damaged eyewear. Other Policy All athletes must report a change in primary care insurance immediately. All athletic related medical services must be pre-approved by the head athletic trainer and the assistant athletic director. This does not include emergencies. Athletes will be held fully responsible for expenses acquired for medical services not approved by the Head Athletic Trainer. All athletes are required to hand carry the University s secondary insurance verification letter to all new providers and to fill out a claim form with the Athletic Trainer. This must be done for each new injury. If an athlete chooses to go to a physician who is not a provider for his/her primary care insurance he/she will be held responsible for all expenses. Athletes are expected to attend all appointments. Athletes are fully responsible for expenses incurred for missed appointments. I hereby acknowledge the above policy and will abide by it. If I/or my dependent(s) do not abide by the policy of the Secondary Insurance provided by California State University, Stanislaus then I will be held for any expenses incurred. Signature of Student Athlete Signature of Parent of Student Athlete

4 Warrior Athletics Student Athlete Authorization Form Please read the following statements carefully and initial the line before each statement. Your initials indicate that you fully understand the statement. If you disagree with the statements below you may decline authorization by signing the Signature to Decline line at the bottom. By signing the bottom you are authorizing the athletic trainer to provide services in a prompt and timely manner. I hereby authorize the Sports Medicine Staff at California State University, Stanislaus to release my Protected Health Information for the purpose of further treatment and billing. I hereby authorize the Sports Medicine Staff and Team Physician/Consultant at California State University, Stanislaus permission to render to myself, and/or son/daughter, any treatment or medical care deemed necessary. I also understand that the treatment rendered does not necessarily qualify me for university s secondary insurance benefits. I hereby authorize the Sports Medicine Staff and Treating Physician/consultant at California State University, Stanislaus permission to disclose information in regard to any injuries/illnesses I may sustain to my Head Coach, Athletic Director, Assistant Athletic Director, Parents/Guardians and/or People listed on my Emergency Contact Information. I understand that under the Family Educational Rights and Privacy Act that I may revoke the above authorizations at anytime. To do so I must submit the revocation in writing. Print Name Signature Parent/Guardian (If under 18 years of age) Signature to decline

5 CONSENT TO TESTING OF URINE SAMPLE AND AUTHORIZATION FOR RELEASE OF INFORMATION Drug Education, Testing and Treatment Program Director I hereby consent to have a sample of my urine collected and tested for the presence of certain drugs or substances in accordance with the provisions of the California State University, Stanislaus Department of Intercollegiate Athletics Drug Education, Testing and Treatment Program, and the NCAA, and at such other times as urinalysis testing is required under the program during the academic year. I further authorize you to make a confidential release to the Program Physician, substance abuse counselor, Director of the Department of Intercollegiate Athletics at California State University, Stanislaus of test results you may have relating to the screening or testing of my urine sample(s) in accordance with the provisions of the California State University, Stanislaus Department of Intercollegiate Athletics Drug Education, Testing and Treatment Program. California State University, Stanislaus, its Board of Regent, it officers, employees and agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this form. Print Name Signature Parent Signature (if under 18)

6 Warrior Athletics Student Athlete Statements of Self Reporting and Medical Compliance Please read the following statements carefully and initial the line before each statement. Your initials indicate that you fully understand the statement. I will promptly report all injuries and illness including signs and symptoms of a concussion to a certified athletic trainer. If an athletic trainer is not immediately available I will report the injury to my coach and make an appointment at the student health center. I will honor and obey all medical advice given to me by all certified athletic trainers and physicians. I will return to activity as directed by a certified athletic trainer and physician. I understand once I see a physician that I may not return to full participation until I have presented the athletic trainer and my coach with written clearance. I acknowledge that I have been presented with educational materials on concussions. Print Name Signature Sport

7 California State Risk Management Authority Intercollegiate Athletic Insurance Questionnaire Accident/Injury benefits for student athletes are provided on an excess basis. This means ATHLETE S OWN GROUP OR THAT OF THE ATHLETE S SPOUSE AND /OR PARENTS MUST BE BILLED FIRST. Benefits are available from our program only when the athlete s coverage is exhausted or does not apply. The following information is essential to assure that expenses are adequately and completely covered by the proper insurance. Inadequate or incomplete answers will delay payment of medical bills and may jeopardize the athlete s credit rating. No medical expenses will be paid out of institutional fund without a signed, accurate questionnaire on file. It is the athlete s sole responsibility to keep the information contained in this document current. Name: Sport: of Birth: SS#: Student ID# Sex: Local School Address: Home Phone # ( Dorm/Street ) Cell # ( ) City State Zip Emergency contact information: Father/ Guardian/Spouse Mother/Guardian Name: Name: Address: Address: Street Street City State Zip City State Zip Home Phone: ( ) Phone: ( ) Cell Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Work Phone: ( ) Do you have primary care health insurance? Yes No If NO, Sign and date the bottom of page! If Yes, Please complete information blow (information is required). Information should be copied from your insurance card. Insurance Company Name: Address: Street City State Zip Insurance Co Phone #: ( ) Plan #: Group #: Plan is under: Father Mother Self Spouse Policy #: ID # : Type of Plan: HMO PPO Family/Private Work Govt Other I hereby certify that the foregoing answers are true, complete, and correct to the best of my knowledge. I also hereby authorize any Insurance company, Organization, employer, Hospital, Physician, Physical Therapist, Pharmacy, or other health care provider to release any information with respect to injury, treatment, or insurance. Athlete s Signature: Please enclose a copy of your insurance card. :

8

Health Status Report

Health Status Report CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA International Center Health Status Report You are required to complete the International Center, Study Abroad Health Status Report. You complete Part I:

More information

2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION

2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION 2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION Returning GCU Student Athletes: Until these forms are complete and you have been released to practice by the Athletic Training Staff, you will not be

More information

Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet

Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet Attention: Returning Student-Athletes Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet On Behalf of the Sports Medicine Department, we look forward to another healthy

More information

Athletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144

Athletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144 Athletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144 Dear Student-Athlete and Parent(s)/Guardian(s): On behalf of the Olivet College Athletic Training Department,

More information

Dear Potomac State College Student Athletes and Parents:

Dear Potomac State College Student Athletes and Parents: Dear Potomac State College Student Athletes and Parents: We are please to have your son/daughter as a student athlete at Potomac State College of West Virginia University and hope that he/she will achieve

More information

Fairfield University Sports Medicine Department 1073 North Benson Road Fairfield, CT 06824

Fairfield University Sports Medicine Department 1073 North Benson Road Fairfield, CT 06824 June 1, 2015 The Fairfield University Sports Medicine Department requires that all student athletes complete several forms before they are eligible to participate with their athletic team in the upcoming

More information

FURMAN UNIVERSITY SPORTSMEDICINE CENTER

FURMAN UNIVERSITY SPORTSMEDICINE CENTER FURMAN UNIVERSITY SPORTSMEDICINE CENTER IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are

More information

UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian:

UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian: UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian: Enclosed is important information regarding athletic accident insurance that requires your immediate attention and response.

More information

The California State University

The California State University The California State University HR 2004-22 PRIVACY NOTICE This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

More information

***COPY OF FRONT AND BACK OF INSURANCE CARD***

***COPY OF FRONT AND BACK OF INSURANCE CARD*** We would like to take a moment to welcome you back for 2015-16 school year at the University of San Francisco. This packet is intended to introduce you to the Sports Medicine staff and to provide information

More information

Gavilan College Sports Medicine Emergency Contact / Insurance Information

Gavilan College Sports Medicine Emergency Contact / Insurance Information Emergency Contact / Insurance Information SPORT(s): NAME: DATE OF BIRTH: YEAR: (Freshman / Sophomore ) SSN: No SSN (initial ) LOCAL ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: (H) (C) (W) E-MAIL Emergency

More information

ATHLETIC PARTICIPATION MEDICAL PACKET (SOPHOMORES)

ATHLETIC PARTICIPATION MEDICAL PACKET (SOPHOMORES) ATHLETIC PARTICIPATION MEDICAL PACKET (SOPHOMORES) Dear Weatherford College Athlete, Athletic Training & Sports Medicine A new year of Weatherford College Athletics is quickly approaching. I hope this

More information

Instructions for Applying for AB-540 California Nonresident Tuition Exemption

Instructions for Applying for AB-540 California Nonresident Tuition Exemption Admissions Office P.O. Box 6900, Fullerton, CA 92834-6900 / T (657)-278-2300 / F (657)-278-7699 AB-540 Instructions for Applying for AB-540 Nonresident Tuition Exemption To apply for exemption from paying

More information

CENTRAL COLLEGE PARENT/GUARDIAN/STUDENT INFORMATION FORM 2013-2014

CENTRAL COLLEGE PARENT/GUARDIAN/STUDENT INFORMATION FORM 2013-2014 CENTRAL COLLEGE PARENT/GUARDIAN/STUDENT INFORMATION FORM 2013-2014 RETURN COMPLETED FORM TO Central College Attn: Frank Neu Campus Box 6600, 812 University St. Pella, IA 50219 If you are filling this out

More information

FURMAN UNIVERSITY SPORTSMEDICINE CENTER

FURMAN UNIVERSITY SPORTSMEDICINE CENTER IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are to be filed with your insurance first.

More information

Truett-McConnell Athletic Training Forms

Truett-McConnell Athletic Training Forms Truett-McConnell Athletic Training Forms Table of contents 1. Welcome letter 2. Assumption of Risk and Consent to Treat 3. Authorization/Consent for Disclosure of Protected Health Information (PHI) 4.

More information

Required Reports Regarding Healthcare-Related Services (AA-2015-08)

Required Reports Regarding Healthcare-Related Services (AA-2015-08) Academic and Student Affairs 401 Golden Shore, 6th Floor Long Beach, CA 90802-4210 www.calstate.edu Loren J. Blanchard Executive Vice Chancellor Tel: 562-951-4710 Email lblanchard@calstate.edu Code: M

More information

2014/15 STUDENT-ATHLETE SPORTS PHYSICAL PACKET

2014/15 STUDENT-ATHLETE SPORTS PHYSICAL PACKET 2014/15 STUDENT-ATHLETE SPORTS PHYSICAL PACKET Athlete Information Form Please complete entire form Athlete Name: Athlete Cell: Sex: M F Age: Graduation Year: Sport(s): Allergies: Medications: Emergency

More information

To the Parents of Varsity Athletes:

To the Parents of Varsity Athletes: To the Parents of Varsity Athletes: We are all familiar with rising health care costs. Valparaiso University, in studying its health costs annually, has to struggle with these same issues. Having reviewed

More information

All forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room 1312 2201 E. Asbury Ave. Denver, CO 80208-3200

All forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room 1312 2201 E. Asbury Ave. Denver, CO 80208-3200 Julie Campbell Director of Sports Medicine (303) 871-3918 Office (303) 871-3666 Fax jcampbel@du.edu To: Re: Returning Student-Athletes 2014-2015 Sports Medicine Medical Information Packets Date: Thursday,

More information

PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider

PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider All full-time, undergraduate students must have a physical exam. PERSONAL DATA Name: Last First Middle Birthdate: Height: Weight:

More information

Human Services. LOWER-DIVISION TRANSFER PATTERN California State University (CSU) Statewide Pattern

Human Services. LOWER-DIVISION TRANSFER PATTERN California State University (CSU) Statewide Pattern July 21, 2009 California State University (CSU) Statewide Pattern The Lower-Division Transfer Pattern (LDTP) consists of the CSU statewide pattern of coursework outlined below, plus campus-specific coursework,

More information

Introduction. Degree Disciplines

Introduction. Degree Disciplines Introduction The California State University has awarded more higher education degrees than any other college or university in California over the past few years. Since 1975-1976, about half of all baccalaureate

More information

THE UNIVERSITY OF TEXAS AT AUSTIN Texas Longhorn Boys Basketball Camp Fax: 512-471-4160 ATTN: Leslie Parks P.O. Box 7399 Austin, Texas 78713-7399

THE UNIVERSITY OF TEXAS AT AUSTIN Texas Longhorn Boys Basketball Camp Fax: 512-471-4160 ATTN: Leslie Parks P.O. Box 7399 Austin, Texas 78713-7399 #1 Texas Longhorn Boys Basketball Camp Fax: 512-471-4160 ATTN: Leslie Parks P.O. Box 7399 Austin, Texas 78713-7399 UNIVERSITY SPONSORED SUMMER SPORTS CAMPS M E M O R A N D U M DATE: TO: FROM: RE: Prospective

More information

Campus Presidents are responsible for compliance with these requirements.

Campus Presidents are responsible for compliance with these requirements. Office of the Chancellor 401 Golden Shore, 4 th Floor Long Beach, CA 90802-4210 562-951-4411 email: hradmin@calstate.edu Date: May 21, 2009 Code: HR 2009-08 To: From: Subject: CSU Presidents Gail E. Brooks

More information

Albright College Sports Medicine Medical Insurance Information

Albright College Sports Medicine Medical Insurance Information Albright College Sports Medicine Medical Insurance Information Please complete the following information about the student athlete. Name: Year in college: Fr So Jr Sr 5th Social Security: Age: Date of

More information

Pre-Participation Physical Evaluation

Pre-Participation Physical Evaluation 1 Dear Returning YHC Student-Athlete and Parents/Guardians, As a Young Harris College student-athlete, we certainly hope that medical treatment for a serious injury is not necessary, but in the event that

More information

INVENTORY OF THE CALIFORNIA STATE UNIVERSITY CATALOG COLLECTION, 1933-1995

INVENTORY OF THE CALIFORNIA STATE UNIVERSITY CATALOG COLLECTION, 1933-1995 http://oac.cdlib.org/findaid/ark:/13030/kt9m3nd1bd No online items COLLECTION, 1933-1995 Finding aid prepared by Greg Williams California State University, Dominguez Hills Archives & Special Collections

More information

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home

More information

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a

More information

TECHNICAL LETTER HR/WB 2012-01 Page 2 of 2

TECHNICAL LETTER HR/WB 2012-01 Page 2 of 2 TECHNICAL LETTER HR/WB 2012-01 Page 2 of 2 Campuses are required to print the BSA poster, which is located at http://www.bsa.ca.gov/pdfs/other/whstlblr.pdf. Campuses must add the name, title, campus address,

More information

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments

More information

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency

More information

UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT

UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT Release and Waiver of Liability, Assumption of Risk, Indemnity and Hold Harmless Agreements The signed student-athlete is enrolled at the University

More information

MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE HEALTH INSURANCE INFORMATION SCHOLARSHIP AND WALK-ON STUDENT ATHLETES

MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE HEALTH INSURANCE INFORMATION SCHOLARSHIP AND WALK-ON STUDENT ATHLETES MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE HEALTH INSURANCE INFORMATION SCHOLARSHIP AND WALK-ON STUDENT ATHLETES In the event that your son/daughter is injured while participating

More information

University of West Florida Sports Medicine

University of West Florida Sports Medicine University of West Florida Dear Argonaut, On behalf of the UWF Staff, I would like to welcome you to UWF and congratulate you on joining the UWF Athletic Department. I would like to take this time to inform

More information

LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP. TODAYS DATE:, 20 Sport:

LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP. TODAYS DATE:, 20 Sport: LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP Pages 1 & 2 are to be completed by the student-athlete and/or his/her parent/guardian and taken along with page 3 to physician or health care professional

More information

CALIFORNIA STATE UNIVERSITY, LOS ANGELES COLLEGE OF HEALTH AND HUMAN SERVICES School of Kinesiology and Nutritional Science

CALIFORNIA STATE UNIVERSITY, LOS ANGELES COLLEGE OF HEALTH AND HUMAN SERVICES School of Kinesiology and Nutritional Science December 1, 2015 CALIFORNIA STATE UNIVERSITY, LOS ANGELES COLLEGE OF HEALTH AND HUMAN SERVICES School of Kinesiology and Nutritional Science Dear Student: We note with pleasure your interest in our Coordinated

More information

o Complete your Pre-participation Physical exam form, then take it to your sports physical appointment at the campus Health and Wellness Center.

o Complete your Pre-participation Physical exam form, then take it to your sports physical appointment at the campus Health and Wellness Center. Physical Paperwork Worksheet Team: Physical forms deadline: Athlete s Name YOU WILL MISS TRY-OUTS/ PRACTICE TIME IF YOU SUBMIT LATE, INCOMPLETE OR INACCURATE FORMS 1. Schedule your sports physical with

More information

Dominican University of California Office of Athletic Training Athletic Insurance Policies and Procedures

Dominican University of California Office of Athletic Training Athletic Insurance Policies and Procedures Athletic Insurance Policies and Procedures 1. Insurance: a. Personal Insurance: Primary coverage. i. All Dominican university student athletes are required to have a full coverage medical insurance policy

More information

E. SFS verifies the beginning and ending pay warrant number for all live (green) and advice (white) pay warrants for each delivery from the SCO.

E. SFS verifies the beginning and ending pay warrant number for all live (green) and advice (white) pay warrants for each delivery from the SCO. PAY WARRANT DISTRIBUTION PROCEDURE Purpose: To safeguard pay warrants from being distributed to unauthorized persons and to guard against misappropriation of funds. Definition: The pay warrant distribution

More information

H. Res. 1117 In the House of Representatives, U. S.,

H. Res. 1117 In the House of Representatives, U. S., H. Res. 1117 In the House of Representatives, U. S., March 3, 2010. Whereas the California State University system will be celebrating its 50th anniversary during 2010 and 2011; Whereas the individual

More information

Portland State University Sports Medicine Returning Student Athlete Health Report Form

Portland State University Sports Medicine Returning Student Athlete Health Report Form Portland State University Sports Medicine Returning Student Athlete Health Report Form All the following forms must be completed and submitted to the Sports Medicine Department annually. It needs to be

More information

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp

More information

CSU vs. UC. What s the Difference? Presented by: Lorena N. Ochoa, Transfer Counselor Victor Valley College

CSU vs. UC. What s the Difference? Presented by: Lorena N. Ochoa, Transfer Counselor Victor Valley College vs.. What s the Difference? Presented by: Lorena N. Ochoa, Transfer Counselor Victor Valley College and Campuses 10 Campuses Berkeley Davis Irvine Los Angeles Merced Riverside San Diego San Francisco (only

More information

2014-15 Point Park University Medical Packet CONTENTS

2014-15 Point Park University Medical Packet CONTENTS 2014-15 Point Park University Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2014-15 year. Please return all completed forms

More information

The State University System. Presented by the WHS Counseling Department

The State University System. Presented by the WHS Counseling Department The State University System Presented by the WHS Counseling Department State Colleges Federal law requires a two tier post secondary education system in each state. Therefore you will find a university

More information

Missouri Valley College Sports Medicine Staff

Missouri Valley College Sports Medicine Staff MISSOURI VALLEY COLLEGE SPORTS MEDICINE POLICY AND PROCEDURE Athletes Name: Sport: Please review all of the forms in this packet. Each of the forms contains information important to the student athlete.

More information

REHAB XCEL, LLC. NEW PATIENT INFORMATION

REHAB XCEL, LLC. NEW PATIENT INFORMATION REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S

More information

NAME: (PRINT) First Last. College M#:

NAME: (PRINT) First Last. College M#: SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from

More information

Type of Colleges. California Colleges. Myths. Community Colleges. The Basics. Transferring and Degrees 3/16/15. Madera Community College Center

Type of Colleges. California Colleges. Myths. Community Colleges. The Basics. Transferring and Degrees 3/16/15. Madera Community College Center California Colleges Presented by: Norma I. Cuevas, Lydia Moua & Walter Ramirez Upward Bound Programs Fresno State *information used from 2013 statistics provided online by each institution. Type of Colleges

More information

We hope you will consider this opportunity to jump start your BSN! THE CALIFORNIA STATE UNIVERSITY

We hope you will consider this opportunity to jump start your BSN! THE CALIFORNIA STATE UNIVERSITY College of Health and Human Development School of Nursing P.O. Box 6868, Fullerton, CA 92834/92831 / T 657-278-3336 / F 657-278-3338 Email: nursing@fullerton.edu / Website: http://nursing.fullerton.edu

More information

Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST

Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Page 2 (Physical Examination Form): Page two of this packet is the ONLY

More information

SANTA PAULA HIGH SCHOOL Sports/Co-curricular Participation Screening Examination

SANTA PAULA HIGH SCHOOL Sports/Co-curricular Participation Screening Examination Sports: Student ID#: SANTA PAULA HIGH SCHOOL Sports/Co-curricular Participation Screening Examination Name Birth Date Current Grade Home Address Home Phone Parent(s)/Guardian(s) Name Have you ever (Circle

More information

The following is a checklist, for your personal use, of all the forms that must be returned to Manhattanville College Sports Medicine by August 1:

The following is a checklist, for your personal use, of all the forms that must be returned to Manhattanville College Sports Medicine by August 1: Dear new student athlete: The Sports Medicine Staff would like to take this opportunity to welcome you to Manhattanville College. We work to provide all student athletes with comprehensive health care

More information

www.goleathernecks.com

www.goleathernecks.com Dear Student-Athlete, Welcome back to Western Illinois University! The Sports Medicine Department provides comprehensive medical care for injuries and illnesses suffered while competing as a WIU student-athlete.

More information

Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES)

Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES) Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES) PLEASE PRINT ALL INFORMATION CLEARLY AND COMPLETELY! Student-Athlete s Name: SS# - - DOB / /19 (mm/dd/year)

More information

ASSOCIATE IN SCIENCE FOR TRANSFER - BUSINESS ADMINISTRATION (PRIMARILY FOR TRANSFER TO THE CSU -- SEE DETAILS BELOW)

ASSOCIATE IN SCIENCE FOR TRANSFER - BUSINESS ADMINISTRATION (PRIMARILY FOR TRANSFER TO THE CSU -- SEE DETAILS BELOW) A Course of Study for ASSOCIATE IN SCIENCE FOR TRANSFER - BUSINESS ADMINISTRATION (PRIMARILY FOR TRANSFER TO THE CSU -- SEE DETAILS BELOW) Upon successful completion of the Santa Monica College AS-T in

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

Christian Brothers University Medical Certification for individual Student Athlete Participation: MUST EACH 1. pre participation physical: 2. 3. 4.

Christian Brothers University Medical Certification for individual Student Athlete Participation: MUST EACH 1. pre participation physical: 2. 3. 4. Christian Brothers University Medical Care and Insurance Procedures (Revised 12/8/14) Medical Certification for individual Student Athlete Participation: Christian Brothers University requires all student-athletes

More information

California State University A Parent s Guide. Presented by the WHS Counseling Department

California State University A Parent s Guide. Presented by the WHS Counseling Department California State University A Parent s Guide Presented by the WHS Counseling Department 23 CSU Campuses! California State Universities (CSU) Apply to each campus separately using one online application

More information

Per Year ESTIMATED College Costs

Per Year ESTIMATED College Costs Per Year ESTIMATED College Costs 2010-2011 Registration Fees and Tuition* Community College CSU UC Private/ Independent $686 - $802 $4,810 - $6,498 $11,030 - $15,308 $25,881 - $40,384 Books and Supplies

More information

2015-16 Point Park University Athletics Medical Packet CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!

2015-16 Point Park University Athletics Medical Packet CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY! 2015-16 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2015-16 year. Please return all completed

More information

TARLETON SPORTS MEDICINE. Student-Athlete Medical Information

TARLETON SPORTS MEDICINE. Student-Athlete Medical Information TARLETON SPORTS MEDICINE Student-Athlete Medical Information TARLETON STATE UNIVERSITY ATHLETICS DEPARTMENT Box T-0080 Stephenville, TX 76402 254-968-9178 254-968-9674 FAX www.tarletonsports.com Dear Parent

More information

II. Returning student-athletes must update their information each year.

II. Returning student-athletes must update their information each year. General Policies: The Alcorn State University Sports Medicine Program aims to provide prevention, treatment, and rehabilitation of athletic injuries and ensure the highest standard of medical care for

More information

Ave Maria University Athletic Insurance Policy and Procedures: Ave Maria University s Insurance Policy Description

Ave Maria University Athletic Insurance Policy and Procedures: Ave Maria University s Insurance Policy Description AVE MARIA UNIVERSITY Athletic Training Sports Medicine Insurance Policies and Procedures Ave Maria University Athletic Insurance Policy and Procedures: The NAIA provides a Catastrophic Injury Insurance

More information

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a

More information

CONSENT FOR MEDICAL TREATMENT

CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

More information

Memorandum CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA. Claudia Pinter-Lucke Peggy Kelly Carol Putnam. Date: May 3, 2012

Memorandum CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA. Claudia Pinter-Lucke Peggy Kelly Carol Putnam. Date: May 3, 2012 CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA Office of the President Memorandum Date: May 3, 2012 To: Marten denboer Provost and Vice President for Academic Affairs From: ~~ J. Michael Ortiz President

More information

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509

11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509 PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED

More information

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP 2011 SUMMER FASHION PROGRAM STUDENT APPLICATION CHECKLIST To apply for the Summer Fashion Program, please submit the required documents to The Center for Global

More information

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey

More information

CHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM

CHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM CHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM PROGRAM/CAMP INFORMATION Parents and legal guardians are responsible for carefully reviewing all program materials and for selecting programs

More information

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

WICOMICO COUNTY ATHLETIC PACKET

WICOMICO COUNTY ATHLETIC PACKET Emergency Form and Medical History LAST NAME: FIRST: M.I. SEX: MALE FEMALE Date of Birth: / / Sports: Grade: School: SSN: Parent/Guardian Home Phone Cell Phone Work Phone Emergency Contact-In the event

More information

UNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES

UNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES 1 UNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES 1. Athletic Insurance Coverage. Revised 2009 Insurance coverage for any injury sustained while participating in an intercollegiate sport at

More information

Dear Alderson Broaddus Student-Athlete:

Dear Alderson Broaddus Student-Athlete: Dear Alderson Broaddus Student-Athlete: Welcome back for another exciting year at Alderson Broaddus University! In preparation for the beginning of the academic year, and your participation in intercollegiate

More information

Patient Registration Please Print Patient Name Last First Middle

Patient Registration Please Print Patient Name Last First Middle Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact

More information

626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 PATIENT INFORMAION PARENT INFORMAION INSURANCE INFORMATION (PARENT WHO PAYS FOR INSURANCE)

626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 PATIENT INFORMAION PARENT INFORMAION INSURANCE INFORMATION (PARENT WHO PAYS FOR INSURANCE) WESTCARE VILLA RICA PEDIATRICS 626 Dallas Hwy PO Box 1008 Villa Rica, GA 30180 Phone: 770 459 9378 Fax: 770 459 8613 Email: westcarepeds@aol.com DATE PATIENT INFORMAION Child s Name Date of Birth Sex Address

More information

Name: Grade: Age: Answer the following questions as accurately as possible. (Explain yes answers below.) SINCE YOUR LAST PHYSICAL EXAMINATION: Yes No

Name: Grade: Age: Answer the following questions as accurately as possible. (Explain yes answers below.) SINCE YOUR LAST PHYSICAL EXAMINATION: Yes No TRUMANSBURG CENTRAL SCHOOL SPORTS CANDIDATE QUESTIONNAIRE This packet needs to be filled out within 30 days from the beginning of the season and turned into the nurse no later than 1 week prior to the

More information

Saint Joseph s University Club Sport Athlete Participation Packet (8/2015)

Saint Joseph s University Club Sport Athlete Participation Packet (8/2015) Saint Joseph s University Club Sport Athlete Participation Packet (8/2015) These forms must be read and completed in entirety before an athlete can compete for a SJU Club Sport. This includes tryouts,

More information

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on

More information

Central Michigan University Athletic Department Sports Medicine Services. Mission Statement. Section I Professional Medical Staff / Facilities

Central Michigan University Athletic Department Sports Medicine Services. Mission Statement. Section I Professional Medical Staff / Facilities Central Michigan University Athletic Department Sports Medicine Services Mission Statement "Central Michigan University Athletic Department is committed to providing all student-athletes a level of care

More information

THE CALIFORNIA STATE UNIVERSITY

THE CALIFORNIA STATE UNIVERSITY THE CALIFORNIA STATE UNIVERSITY OFFICE OF THE CHANCELLOR BAKERSFIELD CHANNEL ISLANDS CHICO DOMINGUEZ HILLS December 6, 2012 M E M O R A N D U M EAST BAY FRESNO FULLERTON TO: FROM: CSU Presidents Charles

More information

Frequently Asked Questions

Frequently Asked Questions Frequently Asked Questions Category I Per-Unit Fee for Courses Required in State-Supported Graduate Professional Business Programs BACKGROUND What CSU authority approved the new graduate professional business

More information

19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405

19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 Welcome to our practice. We are happy that you selected us as your eye care provider and appreciate the opportunity

More information

SPORTS MEDICINE PRE-PARTICIPATION PHYSICAL EXAMINATION FORMS RETURNING ATHLETE

SPORTS MEDICINE PRE-PARTICIPATION PHYSICAL EXAMINATION FORMS RETURNING ATHLETE SPORTS MEDICINE PRE-PARTICIPATION PHYSICAL EXAMINATION FORMS RETURNING ATHLETE UNIVERSITY OF ARKANSAS ATHLETIC TRAINING DEMOGRAPHIC INFORMATION FORM Full Name: M F : (Last) (First) (MI) (Circle) (m/dd/yy)

More information

Date: June 01, 2012 Subject: Technical Letter re: California State University Insurance Requirements Code: RM 2012-01

Date: June 01, 2012 Subject: Technical Letter re: California State University Insurance Requirements Code: RM 2012-01 To: Campus Presidents Campus Administrative Vice Presidents Auxiliary Organizations Campus Risk Managers Contract & Procurement Directors Executive Facilities Officers From: Charlene Minnick, Assistant

More information

Department of Athletics Policy & Procedure Manual

Department of Athletics Policy & Procedure Manual 07/2007 03-07 1 of 3 GENERAL INFORMATION Each student-athlete must complete a comprehensive physical exam prior to participation in athletics at Southeast Missouri State University. Annual physical exams

More information

Transfer Associates Degrees - Similar CSU Programs

Transfer Associates Degrees - Similar CSU Programs CSU Campus Bachelors Name Communications Bakersfield BA Communications Mathematics Bakersfield BS Mathematics (Applied option) Mathematics Bakersfield BS Mathematics (Statistics option) Mathematics Bakersfield

More information

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):

More information

REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)

REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,

More information

April 1, 2015. Dear Parents and Student Athletes,

April 1, 2015. Dear Parents and Student Athletes, April 1, 2015 Dear Parents and Student Athletes, Enclosed you will find a packet of information that includes a medical history, waivers, and insurance information forms which need to be filled out in

More information

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

More information

WELCOME TO TRI-COUNTY EYE CLINIC

WELCOME TO TRI-COUNTY EYE CLINIC WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,

More information

ELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES

ELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES ELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES Medical Eligibility for Freshman and Transfer Students: All students who wish to participate in intercollegiate athletics

More information

Sports Medicine Policies & Procedures

Sports Medicine Policies & Procedures Sports Medicine Policies & Procedures The Sports medicine department is organized to provide high quality medical care to all student-athletes within intercollegiate athletic program. The health and well-being

More information

Midha Medical Clinic REGISTRATION FORM

Midha Medical Clinic REGISTRATION FORM Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE

More information

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia

More information