ISCF FIGHTERS MEDICAL ATTENTION FORM
This form is for the event Fighter to present for Medical Attention at the Hospital or Doctors Office chosen.

• FIGHTER: _______________________________________
  
  
• PROMOTER:_____________________________________
  
  
• PROMOTER CONTACT INFO:______________________________
  
  
• DATE: ___/___ 200____
  
  
• VENUE NAME:__________________________________________
  
  
• EVENT CITY: __________________________ STATE:________
  
  
• PHYSICIANS EXPLANATION OF MEDICAL ISSUE OR NEEDS OF ATTENTION:
  
  __________________________________________________________________________
  
  __________________________________________________________________________
  
  
• REQUIRE OR SUGGESTED MEDICAL TESTS: _________________________________________________
  
  
• PROMOTERS INSURANCE COMPANY ______________________________________________________
  
  CONTACT INFO:____________________________________________________
  
  
• INSURANCE POLICY NUMBER __________________________________________
  
  

Executed at _________________AM/PM, on this _________day of _________________, in the year 200___

FIGHTERS PRINTED NAME: _________________________________________________________

FIGHTERS SIGNATURE: __________________________________________ DATE: _____/_____ 200___

PROMOTERS PRINTED NAME: _________________________________________________________

PROMOTERS SIGNATURE: __________________________________________ DATE: _____/_____ 200___

ISCF REPRESENTATIVES PRINTED NAME: _______________________________________

ISCF REPRESENTATIVES SIGNATURE: _______________________________ DATE: _____/_____ 200___

EVENT MEDICAL DOCTORS PRINTED NAME: ______________________________________

EVENT MEDICAL DOCTORS SIGNATURE: ______________________________ DATE: _____/_____ 200___

ISCF - International Sport Combat Federation
P. O. Box 1205, Newcastle, CA, 95658, 9385 Old State Highway, Newcastle, CA, 95658, USA
(916) 663-2467, Fax: (916) 663-4510 or info@iscfmma.com - www.ISCFMMA.com