Baseline Concussion Testing Registration Form

Athlete's Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Birth Date - must be 10 yrs old on date of testing*

MonthDayYear

Age*

Athlete's Physician/Pediatrician*

Physician Phone Number*

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

Did you have a baseline concussion test with us before and this is your yearly retest?*

YesNo

Sports League affiliation*

Preferred date of testing*

Would like a call to schedule to perform at db Orthopedic Physical Therapy - LincroftWould like a call to schedule to perform at db Orthopedic Physical Therapy - ManalapanRequesting on-site testing for groups of 5 or more athletesOn-site testing at Concussion in Youth Sports Lecture on Aug 13, 2014 at IPlay America between 7:30-9:30pm

How did you hear about us?*

Would you like to receive our monthly e-newsletter to keep abreast of health and concussion related topics? You can opt out at any time and there is no obligation.*

YesNo

The cost of the complete concussion baseline testing program entitles the athlete to a baseline cognitive and balance test as well as follow-up tests 24-72 hrs after a head injury and 5-10 days later. The post-injury balance tests will be performed at db Orthopedic Physical Therapy, PC and require scheduling by calling 732-747-1262. Follow-up testing is included in the initial fee for a period up to one year from the date of baseline testing. The test results will be shared with your physician on record or a physician of your choosing. After submission of the registration form you will be contacted via email to schedule your baseline balance test. Payment is required and a consent form must be completed on the day balance testing is scheduled. Once you complete the balance test and make payment, a second email will be sent outlining the procedures to perform the baseline cognitive test at home under a parent/guardian supervision. If you are participating in a group or sports league testing day, payment by cash, credit card or check made out to db Orthopedic PT will be accepted on the day of testing. To find out more information go to www.concussionRXcare.com. 732 Newman Springs Road, Suite 300 Lincroft, NJ 07738