Has any member of your family under age 50 had these conditions?
ATHLETE'S ORTHOPAEDIC HISTORY
Has the athlete had any of the following injuries?
ATHLETE'S MEDICAL HISTORY
Has the athlete had any of these conditions?
To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals providing services may be immune from liability under Mississippi law.
This waiver, executed by given date above by physician and patient, is executed in compliance with Mississippi law, with the full understanding that if a physician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.
Patient's Parent or Guardian (If Patient is 17 or younger)
Information below to be filled out by physician only
I. Spine / Neck:
II. Upper Extremity:
Hand / Fingers:
III. Lower Extremity:
General Medical Exam
Hernia (if Needed):
Back Ext / Flex:
PHYSICIAN - WHITE SCHOOL - CANARY PARENT/GUARDIAN - PINK
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