Certified Athletic Trainer (ATC) Appointment Request

Rothman 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.

Athletic Trainer Name*
Please enter the Trainer's name

Athletic Trainer Email*
Please enter the Trainer's email

Athletic Trainer phone*
Please enter the Trainer's phone

Athlete name
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Athlete Date of Birth
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Athlete Injury
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Parent's name
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Parent's phone number
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Parents' email
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With whom should we follow up?
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School or Team Affiliations
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Insurance
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Is the Athlete a previous patient of Rothman Institute?
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Requested Physician
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Security Validation
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