Physico Health Assessments is pleased to provide sports physicals to the
students at your child's school.  The Family Nurse Practitioners of
Physico will conduct the physicals in private.  We will send our results
home with your student, along with any recommendations we may have. If
you have any questions, please call us at 480-510-3075, or email us at
Physico2go@yahoo.com.

Physico Health Assessments is a separate entity from your students
school.  Physico is fully insured and assumes liability for the medical
decisions made by the owners/Nurse Practitioners, thereby releasing your
students school from all liability relating to the services provided by
Physico Health Assessments.

IMPORTANT:   Your child needs to bring $25.00 in cash, and this
consent form along with the Sports Physical Form with the Health History
part completed and signed by the parent or guardian.

Sign and return the bottom portion of this page, keep the top portion.
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Initials ____     I, ____________________________give my permission for
my child, _______________________________to obtain a sports physical
provided by Physico Health Assessments.  I recognize that Physico, not
the school, is liable for the medical decisions made by the Nurse
Practitioners. I know that I will receive a report of any health care
concerns discovered during the exam.

____       I also give permission for my child's physical form to be
released to the Athletic Dept. at his/her school.

____       The Nurse Practitioners will discuss their findings with the
student and parent as appropriate.  The parent will receive a report of
the findings also.

_________________________________________________________________________
Signature of parent/legal guardian                               Date