RoG_Participant_App_PhysiciansForms

PHYSICIAN'S RELEASE

This form must be completed and updated annually by the Participant's Physician with required signature.
Physician, please note - the conditions noted on the accompanying medical history, if present, may represent precautions or contraindications to equine assisted activities. Therefore, when reviewing the medical history, please note whether these conditions are present and to what degree. Please be as specific as possible so that we may best serve the client's needs. Rhythms of Grace will make the final determination about an individual's ability to participate in the program.
Patient Name

First NameLast Name
Patient Name
Date of Birth

MonthDayYear
Date
ICD 10 Code
Patient Primary Diagnosis
Secondary Diagnosis
Other
Height
Weight
Specific limitations not noted on the medical history
ALL Participants with Down Syndrome - PLEASE NOTE - Rhythms of Grace requires:

1. An annual medical clearance from a licensed physician that includes a neurological exam that specifically denies any symptoms consistent with atlantoaxial instability (AAI).

Interpretation: Neurologic signs of AAI always supersede radiographs. The presence of the neurological disorder must be evaluated annually by a physician and is a contraindication for mounted equine activities.The annual neurological examination must be done for all participants with Down syndrome even if the program system for updating participant information does not require a complete new set of forms each year. The participant with Down syndrome must have a written statement from the physician that the exam did not reveal AAI or focal neurologic disorder. This may be included on the medical clearance form or could be a separate document.

This certification of the absence of signs of AAI or decrease of neurologic function by the physician must be completed prior to starting mounted services and an annual re-certification should be completed for continuing participants.
A) Date of Annual Neurological/Physical Exam for AAI/Decreased Neurological Function

MonthDayYear
Date
B) Date of Most Recent Cervical X-Ray for AAI

MonthDayYear
Date
Identify Exam or X-Ray Results as Positive or Negative
I have reviewed the attached medical history and release my patient to participate in appropriate programming at Rhythms of Grace. I am aware and permit my patient to actively participate in the following areas (check all that apply):

Sitting astride a horseGrooming a horseOther equine related ground activitiesNone of the above activities
Given the above diagnosis and medical information, I affirm that this person is not medically precluded from participating in supervised equine-assisted activities. I understand that Rhythms of Grace instructors and therapists will weigh all medical information against any precautions and contraindications. Therefore, I refer this person to Rhythms of Grace for ongoing evaluation to determine further eligibility for participating in supervised equine-assisted activities.
Physician Name
License
LicenseUPIN
Address

Address

Street Address Line 2

CityState

Zip Code
Office Phone
Office Fax
Physicians Signature*

Clear
Date*

MonthDayYear
Date
PHYSICIAN'S PRESCRIPTION FORM

To be completed by Participant's Physician for PT Only. Please provide BOTH Diagnosis and ICD 10 Code - Incomplete Forms will be Returned.
Client Name
Date of Birth

MonthDayYear
Date
Primary Dx
ICD 10 Code
Secondary Dx
ICD 10 Code
Clinical Comments
Evaluate and treat, to include _______ Physical Therapy as a Treatment Tool.

Frequency: Treatment as needed based on Therapist evaluation.

This prescription will be current for one year (12 months) from date of Physician's Signature.
Physician Name
License
LicenseUPIN
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Office Phone
Office Fax
Physicians Signature*

Clear
Date*

MonthDayYear
Date
When completed with ALL SIGNATURES please return this form to:

Rhythms of Grace 23625 River Heights Dr., Dallas Center, IA 50063

Phone: (515) 305-7361

Email: Info@RhythmsOfGraceEquine.org
Should be Empty:

PHYSICIAN'S RELEASE

ALL Participants with Down Syndrome - PLEASE NOTE - Rhythms of Grace requires:

PHYSICIAN'S PRESCRIPTION FORM