Athletic Trainer Referral Form

Athletic Trainer Referral Form

Please fill out the following information and hit "Submit" below. Please note that incomplete submission will not be accepted. We will contact your student to schedule within 24-48 business hours. Please contact us at atcreferral@omgtb.com if you have any questions.
Athletic Trainer Information:
Name of Referring ATC*

First NameLast Name
School Name*
Athlete Demographics:
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Guardian Name*

First NameLast Name
Guardian Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Insurance Information:
Insurance Provide Name*
Member ID*
Subscribers Name*

First NameLast Name
Upload Front of Insurance Card

Cancelof
Upload Back of Insurance Card

Cancelof
Appointment Information
Date of Injury

MonthDayYear
Date
Problem to be Evaluated*
Appointment Location Requested*
Physician Requested*
Any Additional Information
Should be Empty:

Athletic Trainer Information: