Request an Appointment with the Complex Concussion Clinic

Be Advised: This is not confirming an actual appointment.

A member of our complex concussion team will contact you by the next business day to learn more about your condition, confirm your insurance coverage, and schedule an appointment as appropriate.

First Name

Last Name

Phone

Date of Birth

Date of Concussion

Current symptoms

Have you ever served in the U.S. Military?

Please provide the dates of service:

Are you currently a first responder?

Referred By:

Word of MouthOnline SearchHealthcare Provider (Physician, Athletic Trainer, School Nurse, etc.)Other

If you were referred by a Healthcare Provider, please explain.

If Other, please explain.

Healthcare providers whom you have previously seen for concussion care:

Type of Insurance

Insurance Policy Number

Additional Comments

Yes, I would like to learn more about Shepherd Center.