17-03 Annex A Appendix 2 - Attending Physician's Statement
Cadet Administrative and Training Orders (CATOs)
Attending Physician's Statement
Physician’s name:
Adress:
Patient’s name:
Adress:
Diagnosis including complications (if fracture, bone and type of fracture) and Nature of injury:
Date of:
- First attendance
- Actual Loss
Please outline the treatment plan recommended and prescribed:
Date of next scheduled follow up appointment:
Was claimant hospitalized ?: (yes/no)
Names and addresses of other physicians or surgeons, if any, who attended the claimant:
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE:
Date:
Signature:
Adress:
ASSOCIATION’S STATEMENT
Name of Insured:
Insured’s effective date:
Membership number:
Did the injury occur while claimant participating in a sanctioned event?: (yes/no)
Please describe:
Description of injury:
Date:
Signature:
Tel:
Title:
Page details
- Date modified: