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Certified Athletic Trainer (ATC) Appointment Request

Rothman Orthopaedic Institute works directly with sports team and athletic trainers around the region to make sure that student, amateur and professional athletes are all given the best and most immediate care possible when an injury occurs while playing, practicing or training.

Certified Athletic Trainers can schedule appointments for their athletes by using our ATC Appointment Form.

Patient First Name*
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Patient Last Name*
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Patient Date of Birth*
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Parent/Guardian Name*
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Patient Phone Number*
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Patient Insurance
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Will school insurance be used ?*
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Body Part & Diagnosis*
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The Provider following up is aware of the referral*
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ATC Name*
Please enter the ATC's name

ATC Phone Number*
Please enter the ATC's phone number

High School

Notes
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Security Validation
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Online Scheduling

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