Physician Referral Form

Whenever an athlete sees a medical professional outside of the school (MD, PA, ARNP, Chiropractor, Dentist, Orthodontist, etc) they must bring a note back to the Certified Athletic Trainer with the following information:

Date of visit
Diagnosis
Plan of treatment
Clearance to return to play date
Printed name of provider
Signed name of provider

The note below includes that information and will be given to the athlete prior to going to the medical professional if they are told in advance. If not, you may take a blank copy to the medical professional so all information is included.

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