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Physician Release for Equine-Assisted Adaptive Riding

This client wishes to participate in Equine-related activities. The client would be sitting on a horse. We have side walkers available for support. Please determine if this client can safely participate.

Thanks!

First Name

Weight

Height

Last Name

DOB

This patient may participate in this activity.

Yes

Date

MD Signature

I confirm that the information given in this form is true

Thanks for submitting!

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