Athletic Trainer Referral Form

Athletic Trainer Referral Form

Please fill out the following information and hit "Submit" below. We will contact your student to schedule within 24-48 business hours. Please contact us at atcreferral@omgtb.com if you have any questions. INCOMPLETE OR INCORRECT INFORMATION WILL RESULT IN A DELAY IN SCHEDULING YOUR ATHLETE
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
Sex
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: