Medical Consent Form - Tauranga Riding For Disabled printable pdf download

44 Ngapeke Road Welcome Bay RD5 Tauranga 3175

phone 544 1899 fax 544 1894 email info@taurangarda.co.nz

Medical Consent Form

Dear Doctor,

Tauranga Riding for the Disabled (RDA) offers therapeutic riding programs designed to benefit individuals with

disabilities. Lessons are specifically designed to the individual’s needs by a qualified physiotherapist or occupational

therapist.

The following information is required for the purposes of client assessment and program planning and is made

available for reference only by the Group’s health personnel. This assists RDA personnel in providing riding programs

which are suited to the individual rider and are in compliance with New Zealand Riding for the Disabled Association

(NZRDA) safety standards and guidelines. Please find attached a copy of Parent/Guardian Consent form to release

this information.

Information provided is stored and used only in accordance with the Privacy Act 1993.

Please note for safety reasons the person named below is unable to commence a therapeutic riding program until

Tauranga RDA has received and assessed the medical information requested.

Participant Details

First Name __________________________________________ Surname _______________________________

Address ____________________________________________________________________________________

Date of Birth _________________________________________ Ethnic Group ____________________________

Height (m) _________________ Weight (kgs) _____________

Name of Parent/s/ Guardian _____________________________ Phone ________________________________

Doctor to Complete

Diagnosis _____________________________________________________________________________________________

Relevant Medical History

( please see page 2 for conditions which may be contraindicated or require precautionary measures)

______________________________________________________________________________________________________

Surgical procedures/ year _________________________________________________________________________________

______________________________________________________________________________________________________

Orthotics or other devices required __________________________________________________________________________

Medications ____________________________________________________________________________________________

Allergies ______________________________________________________________________________________________

Speech _______________________________________________________________________________________________

Hearing _______________________________________________________________________________________________

Vision ________________________________________________________________________________________________

Infectious disease _______________________________________________________________________________________

Continence ____________________________________________________________________________________________

Other relevant information/ procedures _______________________________________________________________________

Medical Consent Form - Tauranga Riding For Disabled