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General Medical/Physician’s Statement

Date: August 10, 2020

 

Please select who will be participating...
AdultMinor
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First Physician's Name

First Name*

Last Name*

Phone*
First Physician's Date of Birth*
I certify that I am 18 years of age or older
First Physician's Information on Student

Student's Name: *

DOB: *

Height: *

Weight: *

(This student is being considered for equine activities that may include riding horses.)

Please indicate current or past difficulties in the following systems/areas/ surgeries:

Allergies (List Reactions)*
No
Yes
HEENT*
No
Yes
Hearing/Vision*
No
Yes
Speech*
No
Yes
Cardiac*
No
Yes
Circulatory*
No
Yes
Integumentary(Skin)*
No
Yes
Gastrointestional*
No
Yes
Nutrition/Special Diet*
No
Yes
Gentio-Urinary*
No
Yes
Immunity*
No
Yes
History of Chicken Pox*
No
Yes
Pulmonary*
No
Yes
Neurological*
No
Yes
Seizure*
No
Yes

Seizure Type/Date of last Seizure
Shunt*
No
Yes

Shunt Present/Date of last revision
Orthopedic*
No
Yes
Scoliosis*
No
Yes

Scoliosis (Degree of Curve)
Muscular*
No
Yes
Balance*
No
Yes
Braces or Assistive Devices*
No
Yes
AlantoDen's Interval X-ray date and results (required for students with Down Syndrome)*
No
Yes

AlantoDen's Interval X-ray date and results (required for students with Down Syndrome)
Physical Limitations*
No
Yes
Learning Disability*
No
Yes
Cognitive*
No
Yes
Emotional/Psychological*
No
Yes
Tactile Sensation*
No
Yes
Pain*
No
Yes
TB Skin Test*
No
Yes

TB Skin Test Date and Results

Additional Physician Notes:

To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities at King's Stables.  However, I understand that King's Stables will weigh the medical information above against the existing precautions and contraindications.   

I have examined this child and found him/her to be free of contagious and infections diseases.

Assessment completed by:*

Fax Number: *
First Physician's Signature*
Physician's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information on Student

Student's Name: *

DOB: *

Height: *

Weight: *

(This student is being considered for equine activities that may include riding horses.)

Please indicate current or past difficulties in the following systems/areas/ surgeries:

Allergies (List Reactions)*
No
Yes
HEENT*
No
Yes
Hearing/Vision*
No
Yes
Speech*
No
Yes
Cardiac*
No
Yes
Circulatory*
No
Yes
Integumentary(Skin)*
No
Yes
Gastrointestional*
No
Yes
Nutrition/Special Diet*
No
Yes
Gentio-Urinary*
No
Yes
Immunity*
No
Yes
History of Chicken Pox*
No
Yes
Pulmonary*
No
Yes
Neurological*
No
Yes
Seizure*
No
Yes

Seizure Type/Date of last Seizure
Shunt*
No
Yes

Shunt Present/Date of last revision
Orthopedic*
No
Yes
Scoliosis*
No
Yes

Scoliosis (Degree of Curve)
Muscular*
No
Yes
Balance*
No
Yes
Braces or Assistive Devices*
No
Yes
AlantoDen's Interval X-ray date and results (required for students with Down Syndrome)*
No
Yes

AlantoDen's Interval X-ray date and results (required for students with Down Syndrome)
Physical Limitations*
No
Yes
Learning Disability*
No
Yes
Cognitive*
No
Yes
Emotional/Psychological*
No
Yes
Tactile Sensation*
No
Yes
Pain*
No
Yes
TB Skin Test*
No
Yes

TB Skin Test Date and Results

Additional Physician Notes:

To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities at King's Stables.  However, I understand that King's Stables will weigh the medical information above against the existing precautions and contraindications.   

I have examined this child and found him/her to be free of contagious and infections diseases.

Assessment completed by:*

Fax Number: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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