Athletic Waiver

Patient Name

First

Last

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

MEDICAL RECORDS INFORMATION

I Hereby Request That My Medical Records Be Released To:

Physician/Clinic's Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Previous School:

Graduation (MM/DD/YYYY):

Name of Insurance Carrier:

Policy #:

I understand that I waive all responsibility for the APA Post Grad insurance which covers ages 17-19 in the event of injury.

Pre-Participation Medical Screening:

Have you had a concussion?

Yes
No
N/A

Have you been knocked out?

Yes
No
N/A

Have you stayed overnight in a hospital?

Yes
No
N/A

Have you had a neck injury?

Yes
No
N/A

Have you fainted while exercising?

Yes
No
N/A

Have you had an operation?

Yes
No
N/A

Have you had heat exhaustion or heat stroke?

Yes
No
N/A

Have you ever broken a bone

Yes
No
N/A

Do you have/had an irregular heartbeat?

Yes
No
N/A

Do you have/had high blood pressure?

Yes
No
N/A

Do you have/had a heart problem?

Yes
No
N/A

you pressure? Do

Are you currently on medication?

Yes
No
N/A

Do you wear glasses or contact lenses?

Yes
No
N/A

Do you have dental appliances or hearing aids?

Yes
No
N/A

Do you have any allergies that you are aware of?

Yes
No
N/A

Do you have Epilepsy?

Yes
No
N/A

Do you have Asthma?

Yes
No
N/A

Do you have Diabetes?

Yes
No
N/A

Do you have any missing organs or limbs?

Yes
No
N/A

Has a doctor ever restricted you from athletics?

Yes
No
N/A

Has anyone in your immediate family had a heart problem before the age of 40?

Yes
No
N/A

Has a doctor disqualified you from playing sports in the last year?

Yes
No
N/A

Medical Records Release Terms & Conditions

This is where we'd put your full terms and conditions for your release form. This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature

Clear Signature

Date