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
Patient Portal Email Authorization
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.
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.
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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