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Atlanto-Axial X-Ray Verification For Riders with Down Syndrome
Please Print Out this Form and Send/Bring it to Rainbow Stables, at the Address Provided Above.

Client: ___________________________________ Date of Birth: ___________________

Address: _______________________________________

_______________________________________

Telephone: _______________________ Height: ___________ Weight: ___________

 

Name of Physician: _______________________________________

Telephone: _________________________ Fax: ______________________

Date of X-Ray: _________________________

 

Physician's signature: ______________________________________

 

Note: Due to the nature of this activity, persons diagnosed with Down Syndrome cannot be accepted for riding instruction without proof of a negative diagnostic X-ray for atlanto-axial instability. This form must be accompanied by a signed and dated statement from a qualified physician giving the date and result of the diagnostic X-ray.