USA Consent to Treat .pdf
Original filename: USA Consent to Treat.pdf
Title: USA Consent to Treat
This PDF 1.3 document has been generated by Pages / Mac OS X 10.12.2 Quartz PDFContext, and has been sent on pdf-archive.com on 16/01/2017 at 05:42, from IP address 174.219.x.x.
The current document download page has been viewed 259 times.
File size: 46 KB (1 page).
Privacy: public file
Download original PDF file
USA Consent to Treat.pdf (PDF, 46 KB)
Share on social networks
Link to this file download page
Please Select Camp:
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
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 events.
If said participant is covered by any insurance company, please complete the following:
Insurance Company: ___________________________________________________________
Policy Number: _______________________________________________________________
Parent/Guardian/Adult Participant Signature: _____________________________
Excess accident insurance up to $50,000, subject to deductibles, exclusions and certain limitations,
is provided to all USA Hockey registered team participants. For further details visit usahockey.com or
contact USA Hockey at (719) 576-USAH.
Physician’s Name: ________________________________________
Hospital of Choice: ________________________________________________________________________
COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL
If 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 form.
(concussion, skull fracture)
Neck or back injury
High blood pressure
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster?
❑ Yes ❑ No If yes, when? _________________________
Are you currently taking any medications? ❑ Yes ❑ No If yes, please list all medications on back.
Has a doctor placed any restrictions on your activity? ❑ Yes ❑ No If yes, please explain on back.
3C Rev 8/12
When completed send to firstname.lastname@example.org
Link to this page
Use the permanent link to the download page to share your document on Facebook, Twitter, LinkedIn, or directly with a contact by e-Mail, Messenger, Whatsapp, Line..
Use the short link to share your document on Twitter or by text message (SMS)
Copy the following HTML code to share your document on a Website or Blog