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This form is required for individuals at Mercer University who possess medical risk factors that may affect their ability to safely engage in exercise. It must be completed by a physician to ensure

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 your healthcare provider or the relevant authority.
2. Complete the patient’s details at the top of the form, such as name, date of birth, and contact information.
3. Provide details about the reason for the examination or clearance, including any specific requirements.
4. The physician should conduct a thorough medical examination of the patient.
5. The physician must fill out their observations and conclusions in the designated sections of the form.
6. Sign and date the form at the bottom, confirming the accuracy of the information provided.
7. Submit the completed form to the requesting organization, such as a sports team or school, as specified.

Who needs Physician’s Statement and Clearance Form?

1. Individuals participating in sports activities.
2. Students enrolling in physical education classes.
3. Employees returning to work after a medical leave.
4. Patients undergoing specific medical procedures that require clearance.

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What is Physician’s Statement and Clearance Form?

The Physician’s Statement and Clearance Form is a document completed by a licensed healthcare provider that certifies an individual's fitness to participate in specific activities, often required by schools or organizations for safety and legal reasons.

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

Individuals, such as students participating in sports or certain activities, employees in positions with health requirements, or anyone returning to activities after an injury or illness may be required to file this form.

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

To fill out the Physician’s Statement and Clearance Form, a healthcare provider must provide detailed information about the individual's medical history, current health status, and confirm their ability to safely engage in the specified activities.

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

The purpose of the Physician’s Statement and Clearance Form is to ensure that individuals are medically fit to participate in certain activities and to protect their health and safety as well as that of others.

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

The form typically requires the individual's name, date of birth, medical history, results of physical examinations, any relevant health conditions, and the physician's recommendation regarding activity clearance.