Medical Consent and Indemnity Form

Athletes authorize emergency treatment such as anesthesia or transfusions and declare their injury history, allergies, asthma and insurance. Built for clubs and teams that need these details on file before training and competition.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Phone number

Date of birth

Gender

Female Male Non-binary Prefer not to say

I, (full name)

I authorize the following treatment in an emergency

General anesthesia

I consent I do not consent Discuss first

Blood transfusion

I consent I do not consent Discuss first

Traumatic injury needing immediate surgery

I consent I do not consent Discuss first

Medical information

Blood type

Do you object to blood transfusions?

Yes No Not sure

Do you take regular medication?

Yes No Not sure

If yes, please list it

Which vaccinations have you had?

Have you ever had?

Have you ever had a concussion?

Yes No Not sure

Number of times

Approximate date of last concussion

Have you had a head, neck or spinal injury?

Yes No Not sure

If yes, please give details

Any fractures or dislocations in the last 3 years?

Yes No Not sure

If yes, please give details

Do you wear glasses?

Yes No Not sure

Do you wear contact lenses?

Yes No Not sure

What type of contact lenses do you use?

Soft Rigid gas permeable Daily disposable

Do you have asthma?

Yes No Not sure

Do you take asthma medication?

Yes No Not sure

If yes, please give details

Do you bring your medication to training and competition?

Yes No Not applicable

Are you allergic to any of the following?

Are you allergic to any foods?

Yes No Not sure

If yes, please list them

Do you have any medication allergies?

Yes No Not sure

If yes, please list them

Public health insurance number

Do you have ambulance cover?

Yes No Not sure

Do you have private health insurance?

Yes No Not sure

Insurer name

Type of cover

Hospital only Extras only Hospital and extras

Member number

Does it include physiotherapy?

Yes No Not sure

Does it cover you overseas?

Yes No Not sure

Emergency contact 1

First Name

Last Name

Phone number

Relationship

Emergency contact 2

First Name

Last Name

Phone number

Relationship

I agree

I agree to the terms I do not agree I have questions first

Full name

First Name

Last Name

Signature

Sign here

Date signed

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