LEWIS UNIVERSITY SPORTS MEDICINE

Pietro Tonino , MD
Team Physician
Loyola University-Chicago
2160 South First Avenue
Maywood , IL 60153

Elizabeth D'Elia, ATC
Head Athletic Trainer
815.835.5614
deliael@lewisu.edu

Rebecca Northrup, MS, ATC
Assistant Athletic Trainer
815.836.5446
northrre@lewisu.edu

FORMS

Condition of Participation and Medical Consent Authorization Exhibit 2.1

Assumption of Risk Exhibit 2.2

Authorization for Disclosure for Protected Health Information Exhibit 2.3

Medical History Form  Exhibit 2.4

Physical Examination Form Exhibit 2.5

Insurance Introduction Letter Exhibit 2.7

Letter to New Students and Parents - Preseason Sports Exhibit 2.8

Letter to New Students and Parents - Non Preseason Sports Exhibit 2.9

Parent/Insurance Information Form Exhibit 2.10

One University Parkway
Romeoville , IL 60446
Fax: 815.836.5835