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This document serves as a medical clearance form required for participation in the Exercise Science Employee Fitness Program at The College at Brockport, ensuring the safety of participants with medical

How to fill out physicians statement and clearance

How to fill out Physician’s Statement and Clearance Form

1. Obtain the Physician's Statement and Clearance Form from the appropriate source.
2. Fill in the patient's personal information at the top of the form, including name, date of birth, and contact details.
3. Provide details of the medical condition or reason for the assessment, ensuring accuracy.
4. The physician should complete the relevant sections regarding the patient's medical history and current health status.
5. Answer any specific questions related to fitness for certain activities or return to work/school.
6. Sign and date the form in the designated areas at the end of the document.
7. Ensure the form is submitted to the designated office or individual as required.

Who needs Physician’s Statement and Clearance Form?

1. Individuals returning to sports or physical activities post-injury.
2. Students needing clearance to participate in school sports.
3. Employees requiring medical clearance to resume work after a medical leave.
4. Patients undergoing significant medical procedures or treatments that may affect their physical capabilities.

For pdfFiller’s FAQs

What is Physician’s Statement and Clearance Form?

The Physician’s Statement and Clearance Form is a document that provides medical information about an individual's health status, confirming their ability to participate in specific activities, such as sports or other physical events.

Who is required to file Physician’s Statement and Clearance Form?

Typically, athletes or participants in sports programs, educational institutions requiring medical clearance, and individuals involved in certain physical activities or job positions that necessitate health verification must file this form.

How to fill out Physician’s Statement and Clearance Form?

To fill out the form, a licensed physician must complete sections regarding the patient's medical history, any relevant health conditions, and provide their professional opinion on the patient's fitness for the specified activity.

What is the purpose of Physician’s Statement and Clearance Form?

The purpose of the form is to ensure that individuals participate in activities safely, minimizing health risks by confirming that they are medically fit to engage in the intended physical exertion.

What information must be reported on Physician’s Statement and Clearance Form?

The form must report the patient's identifying information, a detailed medical history, any current medications or treatments, results from a physical exam, and the physician's recommendation regarding the individual's ability to participate in the specified activity.