Date of birth:
STEPHEN F. AUSTIN STATE UNIVERSITY
Cell Phone:
ATHLETIC DEPARTMENT – SPORTS MEDICINE CENTER
Email:
INJURY REFERRAL FORM
Home Address:
Male
Street
City
State
Zip Code
Student-Athlete Name:
Date:
/
/
_________________
Female
Sport:
Position Played:
SS#:
-
-
_________________
Student ID #:
Referred to:
Date of Injury (
)
_______________
/
/
mm/dd - hh:mm ap
DOI
Appt. Date/Time:__________________
_________________
□
New Injury / Illness
□
Follow-up Visit -------- Previous Visit:
/
/
_________________
□
Re-Injury
□
Pre-existing Injury -----
Initial DOI:
/
/
Description of Injury or Illness:
Treatment (First Aid, Physical Therapy, Etc.):
Athletic Trainer's
Trainer’s Evaluation Comments:
Evaluation / Comments:
* Physician’s Diagnosis:
* Physician’s Recommendation & Suggested Treatment:
□ No Restrictions / Released
□ Other
□ No Activity
□ No Contact
□ No Running
□ No Weights
□ No
Expected Date of Release
/
/
Follow-up Appointment
/
/
Physician’s Signature
Date
/
/
Referred by:
Jeff Smith
Loree McCary
Head Athletic Trainer
Assistant Athletic Trainer
(Please print name)
Graduate Assistant AT
Josh Lammert
Steve Condon
Assistant Athletic Trainer
Assistant Athletic Trainer
Billing Information:
(____) Apply bill to Athlete’s Insurance Carrier
Jeff Smith
(____) Send all bills to:
P.O. Box 13010, SFA Station
Nacogdoches, TX 75962-3010
(936) 468-4550
(936) 468-4052 Fax
** PLEASE RETURN A COPY OF THIS FORM WITH STUDENT-ATHLETE **