Physician's Referral
Please Print Out this
Form and Send/Bring it to Rainbow Stables, at the Address Provided
Above.
| Form to be type
written or printed |
Easter Seals Child
Yes___ No ___
|
Name:___________________________________
Date of Birth: ___________________ Height: _________
Weight: ________(weight restriction 190 lbs)
School or other: ________________________________________
Grade: _____________
Parent/Legal Guardian: _________________________________
Phone: ______________
Address: ________________________________________
City: _____________________
Postal Code: _______________
Diagnosis: ________________________________________
Medical History: _______________________________________
_______________________________________
Tetanus Immunization - Date of Most Recent Shot:
_________________________________
Surgical Procedures That We Should Be Aware
of: _________________________________
Visual Impairment
(describe): ___________________________________________________________
Hearing Loss
(describe): ____________________________________________________________
Speech Problem No____ Yes____
(describe): __________________________________________________________
Loss of Sensation: _______________________________________
Incontinence No____ Yes____ (describe
type of protective devices used): __________________________
______________________________________
Balance & Co-ordination Normal____
Abnormal____ (describe): _________________________
Muscle Tone Normal____ Abnormal____
(describe): __________________________________
Seizures - describe in detail,
if possible: _______________________________________
Medication No____ Yes____
Please specify: ________________________________________
Braces describe type
Wheelchair________ Walker________ Crutches_______
_______________________________________
Comments: _______________________________________
_______________________________________
In my opinion, This Patient can receive Riding
Instruction Under Supervision.
Date: _________________________
Signed: _______________________________ M.D.
Physician's Name: _____________________________
Address: ______________________
Phone: ___________________
Please fill in with as much pertinent information
as possible. Any other helpful comments would be appreciated by
our consultant physiotherapist and riding instructors.
------ This Referral
is Valid for One Year Only ------
