Get Michigan 4-h Proud Equestrians Program Physician's Referral For ... - Macombcountymi

Completing the Michigan 4-H Proud Equestrians Program Physician's Referral form is essential for individuals seeking to participate in this therapeutic horseback riding program. This guide provides step-by-step instructions to help users navigate the form easily and ensure that all necessary information is included.

Follow the steps to complete your Physician's Referral form.

1. Press the ‘Get Form’ button to access the Physician's Referral form and open it in your preferred editor.
2. Fill out the rider's name, date, address, city, state, zip code, date of birth, height, and weight. If the rider is under 18 years old, include the parent or guardian's information.
3. Provide the diagnosis, including the date of onset. If the diagnosis is Down Syndrome, ensure to attach relevant documentation as specified in the instructions.
4. List any relevant medical history and surgical procedures. Clearly indicate medications being taken and their purposes.
5. Check the appropriate boxes regarding defects present in sight, hearing, speech, and other options. Additional details can be provided in the comments section.
6. Indicate whether any assistive devices such as crutches, wheelchairs, or walkers are used. Specify the type if applicable, and include any important comments related to seizures or incontinence.
7. The physician must complete the signature section, including their signature, date, phone number, and address information.
8. Review all filled sections to ensure accuracy. Once completed, you can save the changes, download, print, or share the form as needed.

Complete your Physician's Referral form online today to participate in the Michigan 4-H Proud Equestrians Program.