WHS Athletics Injury Care/Referral Info
Please let me know about your child's injury and the providers they have seen, so I can stay up to date and keep a good continuum of care for your student-athlete.  Thank you so much!  
- Bethany Shaw, LAT (Licensed Athletic Trainer)
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Email *
Parent Name/Phone #: *
Student-Athlete/Patient Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Date of Injury *
MM
/
DD
/
YYYY
Body Part Injured *
OTHER:
Injured side/area *
Injury / Diagnosis - as specific as possible (from doctor/provider if applicable) *
Have you seen a doctor/medical provider? *
What type of Provider? *
Other/Specify Type of Provider
Clinic/Hospital/Facility Name: *
Other Clinic/Facility:
Doctor/Provider Name: *
Follow up instructions from medical provider:
(i.e. x-ray, MRI, PT, "f/u in 2 weeks", "no weight bearing," etc)
 *
THANK YOU SO MUCH!
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