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This form is to be used after an athlete has been removed from athletic activity due to a suspected concussion and must be signed by their medical provider in order to return without restriction to training, practice or competition.
Rugby (4.18/1,000 AE) Ice hockey (1.20/1,000 AE) American football (0.53/1,000 AE)
First, a player will undergo an initial, brief period of physical and cognitive rest. This takes place 24 to 48 hours after the incident. Players then can gradually become more exposed to activities, as long as they do not provoke or worsen the symptoms of the concussion.
I (patient name) give permission for [practice name] to give me medical treatment. I allow [practice name] to file for insurance benefits to pay for the care I receive. I understand that: [practice name] will have to send my medical record information to my insurance company.