Forms | Communitydot

Community DOT Medical Treatment Authorization and Consent

Parent First and Last Name

Email

Phone

Student First and Last Name

Student Date of Birth

I give permission for my child to receive a physical exam provider by Community DOT

If I am UNABLE TO ATTEND the exam, I give permission for the Community DOT provider to complete my child’s examination, and I waive my right to be present during the exam.

I consent to receiving text message updates regarding my appointment from Community DOT

Type your full legal name as your signature. I confirm that typing my name below represents my signature.

Date

Parental Consent Form - SPORTS PHYSICAL

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