Get the free CONCUSSION MEDICAL RELEASE FORM OLICY 4132 ORIGINAL FORM

CHESTERFIELD COUNTY PUBLIC SCHOOLS CONCUSSION MEDICAL RELEASE FORM POLICY 4132 ORIGINAL FORM July 2013/REVISED August 2015 Dear Licensed Health Care Provider:, a student athlete, was recently removed

How to fill out concussion medical release form

How to fill out a concussion medical release form:

1. Begin by obtaining the concussion medical release form from your healthcare provider or the organization requiring the form.
2. Read the instructions carefully to understand the information requested and any specific guidelines provided.
3. Start by filling in the personal information section, which typically includes your full name, date of birth, address, and contact information.
4. Provide details about your medical history, including any previous concussions or related injuries, past medical conditions, and current medications.
5. If applicable, fill out the section regarding the date and details of the concussion incident, such as how it occurred, any witnesses, and the healthcare professional who diagnosed the concussion.
6. Review the consent and authorization section, which may require your signature to grant permission for the release of medical records related to your concussion. Ensure you understand the implications of this authorization before signing.
7. If you are under 18 years old, a parent or legal guardian will usually need to sign the form along with you.
8. Double-check that all information provided is accurate and legible. Make any necessary corrections or additions before submitting the form.
9. Keep a copy of the completed concussion medical release form for your records if needed in the future.

Who needs a concussion medical release form:

1. Athletes participating in organized sports, especially high-risk activities like football, soccer, or ice hockey, often need to provide a concussion medical release form before being cleared to participate.
2. Students involved in physical education classes or recreational activities at school may also be required to submit a concussion medical release form.
3. Employees in physically demanding professions, such as construction workers or firefighters, may need to provide a concussion medical release form to ensure workplace safety and liability protection.
4. Individuals seeking medical treatment or participating in research studies related to concussions may be asked to fill out a concussion medical release form to provide informed consent and authorization for medical professionals.

Overall, the specific individuals who require a concussion medical release form can vary based on organizational policies and specific circumstances related to potential concussions or head injuries. It is always important to consult with the relevant organization or healthcare provider to determine if a concussion medical release form is necessary in your situation.

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