Become a LEADER in Sports Concussion Management!!

Enroll in our Credentialed ImPACT™ Consultant (CIC) Program™

What do you receive with the CIC Program?

  • A Customized Page on the ImPACT™ Web Site featuring your Clinic/Services
  • A Listing on ImPACT's National Network of Doctors
  • ImPACT™ Marketing Materials
  • Assistance with Media/PR
  • Excellent Referral Opportunities
  • Authorized use of the ImPACT™ CIC Logo for your Marketing Materials and Business Cards

What are the advantages of becoming a CIC?

  • Become an ImPACT™ Partner - as our clientelle grows, your clinic grows
  • Standing out in a competitive marketplace
  • Offering better quality of care for your patients
  • Increased media coverage
  • Significant revenue generating opportunities

STEP ONE:

To become a Credentialed ImPACT Consultant™ (CIC), you must have appropriate education, training, and experience with the ImPACT program. Each CIC must designate a primary contact person for their organization.

Have you previously worked for a clinic that was a CIC?     Yes     No

What type or organization?
 Sports Medicine Center / Hospital / Large Clinic      Small Doctor's Office with 3-5 Doctor / Small Clinic   Individual PhD / MD / DO


Organization:

Organization Name:
Address:
City:
State / Zip:      Country:
Clinic Phone:   Fax Number:
 
Primary Contact:   Position/Title:
Phone Number:   Email:
 
2nd Contact:   Position/Title:
Phone Number:   Email:
 
3rd Contact:   Position/Title:
Phone Number:   Email:


Organizational Setting:

 Hospital/Clinic  Group Practice  Private Practive  Other: 
 High School  College/University  Professional Team  


Educational Background:
Give a brief history of your education including schools attended, graduation dates, majors, etc.:


Professional certifications/licenses:
Note any professional licenses, certifications and special training received. Include state, year and license number:


Membership in professional organizations:

 AACAP  AAFP  AAN  AAP  ACA  ACSM
 AGP  AGS  AMA  AMSSM  AOSSM  AOTA
 INS  NAN  NASP  NATA  APA
  (Psychiatric)		  APA
  (Psychological)
 
 Other: