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26th Symposium
ImPACT™ Form
Appointment Request
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ImPACT™ Form
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Toggle Navigation
HOME
SERVICES
Physicians Services
Neurology
Pain Psychology
COVID-19 Recovery Program
Concussion Care Clinic
Platelet Rich Plasma Therapy
Chiropractic
Healing Arts Center
Physical Therapy
Medical Fitness
Independent Medical Exams
Internal Medicine
Physicians Services
Neurology
Pain Psychology
COVID-19 Recovery Program
Concussion Care Clinic
PRP And Bone Marrow Aspirate
Chiropractic
Healing Arts Center
Physical Therapy
Medical Fitness
Independent Medical Exams
Internal Medicine
OUR TEAM
Physicians
Physical Therapy Staff
Physician Assistants | Nurse Practitioners
Psychology Staff
Medical Fitness
Chiropractic Staff
Healing Arts
LOCATIONS
ABOUT
News & Events
Careers
PATIENT SERVICES
Activate Portal Account
Login to Portal Account
Make a Payment
Signup For EBill Delivery
Patient Forms and Policies
CONTACT
ImPACT™ Registration Form
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ImPACT™ Registration Form
ImPACT™ Registration Form
Kurt Effertz
2021-11-08T08:35:20-05:00
ImPACT™ Registration Form
Instructions:
Please complete the form below. If you are age 12 or above, please select the option below of how you would like the test to be administered to you. If you choose
the online method
, a test code as well as instructions will be e-mailed to you upon submission.
You will then have 7-days to complete this test
. Failure to do so will invalidate the test code and a new one is required. If you chose the clinical version, please indicate a convenient day and time of availability so that we may schedule your appointment. We will do our best to accommodate your availability. Please allow 60 minutes for this appointment. If you are age 11 and under, you will need to be scheduled for this test. You may schedule this appointment within the clinical setting of Northeast Rehab or please contact Dr. Sheryl Oleski for other options.
First Name
(Required)
Last Name
(Required)
Age
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email address of athlete
(Required)
Team name
(Required)
ImPACT™ Test
(Required)
Online
Clinical
Age 12 and up:
Day
(Required)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time
(Required)
Pediatric ImPACT™ Test
Day
(Required)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time
(Required)
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