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)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email address of athlete(Required)

Team name(Required)

ImPACT™ Test(Required)

Age 12 and up:

Day(Required)

Time(Required)

Pediatric ImPACT™ Test

Day(Required)

Time(Required)