Concussion Forms

New patients: Please print and fill out all the forms below. Be sure to bring the completed forms with you for your office visit.

Consent, Payment Policy and Payment Agreement

Message Authorization and Acknowledgement of Notice of Privacy Practices

New Patient History

Patient Information

Patient Portal Email Authorization

Privacy Practices

If you are a new concussion patient who will be seeing any of our Concussion Clinic physicians, please also print and fill out the Concussion Intake Form below and bring it to your office visit as well.

Concussion Intake Form

If you are a follow up concussion patient who will be seeing any of our Concussion Clinic physicians, please fill out the below symptom scale form for your follow up visit.

Follow Up Symptom Scale

If you would like to authorize the use or disclosure of your Protected Health Information (PHI) to a particular person or entity, please use the form below.

Authorization for Use/Disclosure of Protected Health Information


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