by [email protected] | Nov 4, 2014 | Uncategorized
g-Fusion Athlete Intake Date MM slash DD slash YYYY Name First Last Contact Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and...
by [email protected] | Nov 4, 2014 | Uncategorized
Pre-Screen Questionnaire Name First Last Date MM slash DD slash YYYY SexMaleFemaileDate of Birth MM slash DD slash YYYY Sports Team/Blub Have you taken a baseline ImPACT test? Yes No Date of Test MM slash DD slash YYYY Have you ever suffered a concussion? Yes No Was...
by [email protected] | Nov 4, 2014 | Uncategorized
Patient HIPAA Acknowledgement and Consent Form 2 Patient Name* First Last Date of Birth* MM slash DD slash YYYY Notice of Privacy Practices I acknowledge that I have received the practice's Notice of Privacy Practices, which describes the ways in which the practice...
