ImPACT Waiver

ImPACT Waiver (Consent for Release of Baseline Cognitive Testing Info)

Please fill out and submit this digital form to acknowledge the release of cognitive testing results to medical providers.
  • to have a baseline ImPACT® (Immediate Post-Concussion Assessment and Cognitive Testing) test administered by Pacific Sports Spa, LLC. I understand that my child may need to be tested more than once, depending upon the results of the test. Pacific Sports Spa is authorized to release the ImPACT test results to my child’s primary care physician, neurologist, other treating physician, or any licensed healthcare professional as indicated below. I further understand that I can download the ImPACT Passport app for free and have my child’s results stored on my personal phone, ipad or tablet. I understand that general information about the test data may be provided to my child’s guidance counselor and teachers, for their consideration of whether or not to provide temporary academic modifications. I have the authority to act on behalf of the above named child and will indemnify and hold Pacific Sports Spa harmless for all costs it may incur, including reasonable attorney fees, for any claim to the contrary and/or its acts pursuant to this Consent.
  • Name of child's medical provider
  • Medical provider's office address.
  • Medical provider's office phone number.
  • Electronic signature.
  • Parent / guardian contact number.
  • We can also contact you by email, if desired.