Medical Information Release Form
ADVERTISEMENT
1CSRs: PLEASE ATTACH THE COMPLETED PARQ TO THIS FORM
MEDICAL INFORMATION RELEASE FORM
Patient Name: __________________________________________________________________
Address: _______________________________ Phone: _________________________________
The above individual would like to participate in the following:
Bison Recreation Services Membership
The following Bison Recreation Services program:
TO BE COMPLETED BY PHYSICIAN:
The following PAR-Q questions
were answered positively:
fully capable of participating
YES
capable of participating to a limited degree
within the limitations noted below*
Q1. Heart condition
not capable of participating presently, but
Q2. Chest pain during activity
may be considered at a future date
Q3. Chest pain during rest
not capable of participating
Q4. Loss of balance,
dizziness
* Limitations or abnormalities that Bison Recreation
Q5. Bone or joint problem
Services should be aware of:
Q6. Blood Pressure or heart
drugs
_________________________________________
Q7. Other
reason:_______________
_________________________________________
Signed: _____________________________ - M.D.
Date: _______________________________
TO BE COMPLETED BY PATIENT:
"I, ______________________________________, hereby agree to the release of the above
information by my physician. Where my physician has indicated that I am capable of participating to
a limited degree, I understand that it is my responsibility to discuss such limitations with my physician
and follow my physician's recommendations. The University is not responsible for monitoring my
activities."
Signed: __________________________________
Date: ______________________________
Inquiries may be directed to:
Bison Recreation Services
Room 145 Frank Kennedy Centre
University of Manitoba
Winnipeg, Manitoba R3T 2N2
Telephone (204) 474-6100
Fax (204) 474-7503
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal