Physician referral form 2014docx - fcps 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the student's name and ID number at the top of the form. This information is crucial for identifying the student.
3. In the section for practitioners, input the medical diagnosis and specify the date when the student will be re-examined or can return to unrestricted activity.
4. For each activity listed, indicate whether the student can participate by selecting 'YES' or 'NO'. This includes various physical activities such as running, jumping, and weight training.
5. If applicable, complete the concussion section on page 2, indicating participation levels for cognitive and physical activities.
6. Finally, ensure that you sign and print your name at the bottom of the form along with your address and phone number before submitting it to parents or guardians.

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