Physician Release Form

Physician Release Form

Physician Release Form

  • is in need of authorization to begin or continue participating in equine activities, including horseback riding, at Highest Potential Therapy. Please review their previous medical history and provide medical information in the space below. Address occurrences including surgeries, illnesses, hospitalization and changes in medications, treatments, weight or behavior. Please indicate height and weight. For your reference, a list of potential precautions/contraindications is attached.
  • Update with the current condition of the patient
  • For those with Down Syndrome:
    An Atlantoaxial x-ray and annual exam to exclude Atlantoaxial instability for clients with Down Syndrome over the age of 3.
  • Physician Release

    Given the above diagnosis and medical information, this person is not medically precluded from participation in supervised equestrian activities. I understand that Highest Potential Therapy will weigh the medical information indicated above against any existing precautions and/or contraindications before allowing this person to participate in adaptive riding or physical therapy, occupational therapy or speech-language pathology utilizing equine movement as a treatment strategy. Therefore, I refer this person to Highest Potential Therapy for ongoing evaluation to determine eligibility for participation.
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  • MM slash DD slash YYYY
  • Precautions/Contraindications

    Please note that the following conditions may suggest precautions and contraindications to horseback riding. Therefore, when completing this form, please note whether these conditions are present and to what degree.