ImPACT Consent Form
For use of Immediate Post-Concussion Assessment and Cognitive Testing
(ImPACT)
I have read the attached information. I understand its contents. I have been given an
opportunity to ask questions and all questions have been answered to my satisfaction.
opportunity to ask questions and all questions have been answered to my satisfaction.
I _______Agree _______Disagree
To participate in the ImPACT Concussion Management Baseline Program.
Printed Name of Athlete_______________________________Date of Birth___________
Sport(s)_____________________________________________________________________
Signature of Athlete____________________________________Date__________________
Signature of Parent/Guardian____________________________Date________________
Previous Concussion Information
Date Symptoms Experienced Length of Symptoms
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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