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This form is used to refer patients with prolonged concussion symptoms to the Glen Sather Sports Medicine Clinic, a multi-disciplinary clinic specializing in concussion rehabilitation. It outlines important guidelines and necessary patient details for the referral process.

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How to fill out complex concussion referral request

01

Gather all necessary patient information including name, date of birth, and contact details.

02

Obtain relevant medical history including previous concussions and other neurological issues.

03

Clearly document the current symptoms and their duration.

04

Include results from any recent neurological evaluations or imaging studies.

05

Specify the reasons for the referral and what type of follow-up care is needed.

06

Attach copies of any relevant medical records or test results.

07

Ensure that the referral request is signed and dated by the referring physician.

Who needs complex concussion referral request?

01

Patients who have experienced multiple concussions or symptoms persisting over an extended period.

02

Individuals requiring specialized neurological evaluation and management.

03

Athletes needing assessment before returning to sport after a concussion.

04

Patients with unresolved cognitive, emotional, or physical symptoms related to concussion.

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What is complex concussion referral request?

A complex concussion referral request is a formal submission made to seek specialized evaluation and management for concussions that display complicated symptoms or where the standard treatment protocols may not be sufficient.

Who is required to file complex concussion referral request?

Health care providers who assess patients with complicated concussion cases are required to file a complex concussion referral request.

How to fill out complex concussion referral request?

To fill out a complex concussion referral request, the provider must complete the designated form, providing necessary patient information, detailed medical history, an outline of symptoms, and any previous treatments and evaluations.

What is the purpose of complex concussion referral request?

The purpose of a complex concussion referral request is to ensure that patients with complex symptoms receive appropriate specialist care for effective diagnosis and treatment.

What information must be reported on complex concussion referral request?

The request must include patient identification details, a comprehensive description of symptoms, results of any examinations or tests, previous interventions, and the physician's recommendations for specialized care.

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