• Sports Participation History Form

    Sports Participation History Form

  • PLEASE USE THIS FORM IF REQUESTING PIAA, POP WARNER, SPORTS CLEARANCE, CLEARANCE FOR ALL ACTIVITY, GYM OR INTRAMURALS.  There is a $15 charge for this form.

  • Date of Birth*
     - -
  • Please select the type of form requested*

  • Medicines and Allergies

  • If yes, please identify specific allergy (check all that apply)

  • General Questions

  • Heart Health Questions About You

  • Heart Health Questions About Your Family

  • Bone and Joint Questions

  • Medical Questions

  • Is the patient sex male or female?

  • Sex*

  • Signature

    I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct
  • Date*
     - -
  • What type of Insurance does the patient have?*

  • There is no charge for this form because you are filling this out for an upcoming scheduled Well Check visit.  You will only receive a completed form at your visit. 

    If you need this completed form to be pushed to your portal or you need it completed ahead of your appointment, please choose one of the other options above based on your insurance.  

    Please click submit to complete your request.

    Thank you!

     

     

  • There is no charge for this form due to Medicaid Insurance. Please click submit to complete your request.

  • There is a $15 form fee to complete this form or a $30 fee to request the form be completed in less than 2 business days. Please choose an option and enter payment information below. Pre-payment is required to submit the request.*

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    Form Fee Regular Delivery to Patient Portal. Fee For Form Requested on website with usual up to 2 business day delivery (not including weekends)
    Form Fee Regular Delivery to Patient Portal

    Fee For Form Requested on website with usual up to 2 business day delivery (not including weekends)

    $15.00$15.00
      
    Form Fee for Expedited Form. This fee is for a form which needs to be pushed to the portal or picked up in less than 2 business days (not including weekends)
    Form Fee for Expedited Form

    This fee is for a form which needs to be pushed to the portal or picked up in less than 2 business days (not including weekends)

    $30.00$30.00
      
    Total
    $0.00$0.00

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