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    Consent To Treat

    Uploaded by

    Nancy Barton Misiewicz
    This document contains a consent form for USA Hockey to obtain medical care for participants in USA Hockey sanctioned events. It allows USA Hockey and its medical representatives to treat any injuries that may occur. It requests insurance information if the participant has a policy. The participant or guardian signs to provide consent. Excess accident insurance of up to $25,000 is also provided to registered team participants, subject to limitations. An optional medical history form is included to provide medical information to treat any issues.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Consent To Treat

    Uploaded by

    Nancy Barton Misiewicz
    69 views2 pages
    This document contains a consent form for USA Hockey to obtain medical care for participants in USA Hockey sanctioned events. It allows USA Hockey and its medical representatives to treat any injuries that may occur. It requests insurance information if the participant has a policy. The participant or guardian signs to provide consent. Excess accident insurance of up to $25,000 is also provided to registered team participants, subject to limitations. An optional medical history form is included to provide medical information to treat any issues.

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    Consent to Treat

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    This document contains a consent form for USA Hockey to obtain medical care for participants in USA Hockey sanctioned events. It allows USA Hockey and its medical representatives to treat any injuries that may occur. It requests insurance information if the participant has a policy. The participant or guardian signs to provide consent. Excess accident insurance of up to $25,000 is also provided to registered team participants, subject to limitations. An optional medical history form is included to provide medical information to treat any issues.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    69 views2 pages

    Consent To Treat

    Uploaded by

    Nancy Barton Misiewicz
    This document contains a consent form for USA Hockey to obtain medical care for participants in USA Hockey sanctioned events. It allows USA Hockey and its medical representatives to treat any injuries that may occur. It requests insurance information if the participant has a policy. The participant or guardian signs to provide consent. Excess accident insurance of up to $25,000 is also provided to registered team participants, subject to limitations. An optional medical history form is included to provide medical information to treat any issues.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    USA HOCKEY

    CONSENT TO TREAT

    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:
    Name of Insurance Company: ______________________________________________
    Address: ______________________________________________________________
    Policy Number: _________________________________________________________
    Signed: _______________________________________________________________
    (parent/guardian or adult participant)

    Relationship to Athlete: ___________________________________________________


    Home Address: _________________________________________________________
    Phone: (__________)_________________________

    Date: _____________________

    Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain


    limitations, is provided to all USA Hockey registered team participants. For further details
    visit www.usahockey.com or call USA Hockey at 719-576-USAH.

    (over, please)

    3C Rev 3/04

    MEDICAL HISTORY FORM


    (COMPLETION
    Name

    OF THIS SIDE OF THE FORM IS OPTIONAL)

    _____________________________________________________

    Date: _____________

    Address: _____________________________________________________

    Birthdate: ____________

    _____________________________________________________
    Daytime Phone: ___________________________

    Evening Phone: ____________________________

    WHO TO CONTACT IN CASE OF AN EMERGENCY?


    Name: _______________________________________________
    Daytime Phone: ___________________________

    Relationship: __________________

    Evening Phone: ____________________________

    Physician's Name: _____________________________________________________________________


    Daytime Phone: ____________________________

    Evening Phone: ___________________________

    Hospital of Choice: ____________________________________________________________________


    PLEASE COMPLETE THE FOLLOWING:
    If the answer to any of the following questions is or was yes, please describe the problem and its
    implications for proper first aid treatment on a separate piece of paper.
    Have you had (or do you presently have) any of the following?
    Head injury (concussion, skull fracture)
    Fainting spells
    Convulsions/epilepsy
    Neck or back injury
    Asthma
    High blood pressure
    Kidney problems
    Hernia
    Diabetes
    Heart murmur
    Allergies
    Please specify: _____________________________________
    Injuries to:
    Shoulder
    Knee
    Ankle
    Fingers
    Arm
    Other: ______________________________________________
    Impaired vision
    Impaired hearing
    Other: ______________________________________________

    Circle One
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No

    Yes
    Yes
    Yes
    Yes
    Yes

    No
    No
    No
    No
    No

    Yes
    Yes

    No
    No

    Have you had a recent tetanus booster? _____ If so, when? _________________________________
    Are you currently taking any medications? _____ What? Why? _______________________________
    ________________________________________________________________________________
    Has the doctor placed any restrictions on your activity? _____ Explain: _______________________
    ________________________________________________________________________________

    3C Rev 3/04

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