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Concussion Clinic: Referral to PhysicianReason for Referral: Patient requires concussion clinic followup.PATIENT INFORMATION:*FIRST NAME:*LAST NAME:*DOB:STREET ADDRESS:CITY:POSTAL CODE: *PRIMARY PHONE
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Individuals who have been diagnosed with a concussion and are in need of specialized care and treatment from a concussion clinic.

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The final referral form to the concussion clinic is a document used to formally refer a patient for evaluation and treatment following a concussion.
Healthcare providers, such as doctors or specialists, are required to file this form on behalf of patients who have suffered a concussion.
To fill out the form, complete all required fields with the patient's information, provide detailed medical history, and describe the symptoms and any previous treatments.
The purpose of the form is to ensure proper communication and documentation for the referral process to the concussion clinic, which facilitates appropriate care.
Information that must be reported includes patient demographics, medical history, concussion symptoms, and any prior interventions or treatments.
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