Stroke and Brain Injury Services

AbilityPath

Stroke and Brain Injury Services – Medical Release Form

Student Name *

Address *

Date *

Please Note:

Should an accident or illness occur, it may be necessary to provide for local emergency medical service for clients participating in any therapy services at AbilityPath Brain Injury Rehabilitation Services. Please indicate your permission for such treatment by completing and signing the form below.

In case of emergency, AbilityPath Brain Injury Rehabilitation Services is authorized to call 911 for emergency services. If it should be necessary for an ambulance to be obtained, I will assume payment of such a bill.

Client Signature (Full Name) *

Parent/Legal Guardian *

Email *

Date *

Physician Information

Name of Physician *

Doctor's License Number *

Office Phone *

Address: City, State and Zip *

In case of an emergency, please contact:

Name of Caregiver or family member *

Address: City, State and Zip *

Home Phone

Work Phone

Cell Phone *

Stroke and Brain Injury Services