Concussion Service Appointment Request Form
(Only use this form to request an appointment to our Concussion Service)
Patient Name (First & Last):
*
Date of Birth
*
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Health Card Number:
*
Add province eg (AB 12345-1234)
Contact Number:
*
Format: 4031231234
Comments (optional)
e.g. I would like to request a concussion assessment following a recent head injury. I am still experiencing headaches, dizziness and difficulty concentrating.
Disclaimer
Health Plus Medical Clinic (HPM) is committed to protecting the privacy, security, and confidentiality of all personal health information submitted on this form. Information provided is used solely to facilitate your booking request. Only authorized clinic personnel who require access to this information to perform their duties will review, use, or process it. All personal health information is handled in accordance with Alberta’s Health Information Act (HIA) and Health Plus Medical (HPM’s) internal privacy and confidentiality policies. Your information will remain confidential and will not be shared outside the clinic unless required by law. Identifying details may be removed when used for training or internal reporting. For any privacy-related questions or concerns, contact our Clinic Manager or Privacy Officer at manager@healthplusmed.ca
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