Braintree Health Partners | Referral

Concussion / Head Injury Referral

TBI / Concussion Evaluation

2 or more positive symptoms = referral for evaluation

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Patient Name Date of Birth Patient Phone Date of Injury Mechanism of Injury Referring Provider Practice Name Provider Phone Provider Email Attorney / Law Firm, if applicable Symptoms Present Since Injury

Memory problems Difficulty concentrating Slowed thinking Headache Dizziness / balance issues Nausea Light sensitivity Noise sensitivity Vision problems Irritability Anxiety Depression Mood changes Trouble falling asleep Sleeping more than usual Sleeping less than usual

Clinical Indicators

Loss of consciousness Confusion / disorientation Amnesia Symptoms worsening

Notes

Thank you. Braintree received this referral and will contact the referring office to coordinate. Questions: 813-709-3771

Contact Braintree to coordinate the referral and confirm testing requirements: 813-709-3771

Email referrals: [email protected]

Fax referrals: 800-346-7559