Form Sts0144 Orthopedic Injury Assistive Device Authorization Form printable pdf download

Form Sts0144 Orthopedic Injury Assistive Device Authorization Form

St. Lucie Public Schools

Student Services

Orthopedic Injury Assistive Device Authorization Form

___________________________________________

____

__________ _____

Student Name

Sex

DOB

Grade

__________________________________

____ ___________

_______ _____

School Name

Phone

Fax

Dear Parent/Guardian:

In order for your child to use an assistive device during school hours, the school will need the

information on this form from you and the health care provider. Please return this completed form

to the school health room.

************************************************************************************************

This section is to be completed by the parent/guardian

Medical Release

It is necessary for my child ________________________________to have a special assistive

device during school hours. I hereby give permission for release of medical information pertaining

only to the orthopedic injury and prescribed assistive device to the School Board of St. Lucie

County, Florida. This device will be supplied and maintained by me and will arrive at the school in

working order daily. The school and St. Lucie County Health Department personnel will assume

no responsibility for the proper maintenance or delivery of the special assistive device that is

necessary.

Assistive device supplied by the parent: ___________________________________

Parent/Guardian Signature: _______________________________Date:____________

Parent/Guardian Printed Name: ___________________________Phone #:__________

Parent/Guardian Address: ________________________________________________

************************************************************************************************

This section is to be completed by the treating physician

Type of Injury__________________Location______________Date of Injury__________

Activity Level (please check)

□Non-weight bearing

□Partial weight bearing

□Weight bearing to tolerance

□Full weight bearing

Assistive device(s) to be used □Crutches

□Walker

□Wheelchair

□Other _____________

Has the student been instructed in the use of crutches, or other assistive device(s)? □Yes □No

Comments/Special Instructions/Restrictions___________________________________________

This order is effective until_____/_____/_____

(Date)

Physician’s Signature_______________________________________Date__________

Physician’s Printed Name___________________________________Phone_________

STS0144

Form Sts0144 Orthopedic Injury Assistive Device Authorization Form

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