ADULT or PARENT (on behalf of minor): 

Thank you for interest in taking ImPACT.  ImPACT is a battery of computerized tests specifically designed to be sensitive to the effects of sports-related concussions.  As such, you will be asked to answer several questions and take tests that measure your memory, concentration and reaction time; altogether this will take approximately 30 minutes to complete. 

All of the information you are about to give are strictly confidential and will be stored in a HIPPA-compliant, password-protected, fully encrypted server (US).  Such data may be shared with trained clinicians as part of your injury care but will not otherwise be released to anyone without your approval.  You can complete ImPACT testing either before an injury - "baseline" testing - or after you have had a concussion. The baseline assessment is designed to determine where you are presently when you are in your typical state of health; it is not designed to determine if there is anything wrong with you at this time.  If you have a sports-related concussion during the season you will repeat similar tests in your doctor's office and the baseline testing will serve as a comparison point to help determine the nature of your injury and the best management strategy for your individual case.  Completing baseline testing does not constitute a doctor-patient relationship with any member of 

ImPACT is a medical tool and should be treated as such.  Any ImPACT test results should only be interpreted by qualified health care professionals such as a neuropsychologist or a properly trained physician.  Any use by a non-qualified individual could lead to misinterpretation, which could result in incorrect diagnosis or treatment (or non-treatment) and lead to future negative consequences.  No medical test is 100% accurate and ImPACT is designed to be used in conjunction with other medical findings/facts, records and test results. It should be used as part of an overall diagnosis/treatment program for sports concussions. ImPACT test results are important but are not sufficient to either rule in or rule out a concussion. 

You are entitled to have a copy of your ImPACT test results.  However, you should not try to interpret these findings.  This information should be treated in the same careful way as any other medical records you have kept for personal records.  If you have any questions regarding your ImPACT test results completed through this website, please contact Dr. Czarnota at

By accepting the terms above you are acknowledging that you are taking this test voluntarily and you are willing to submit personally identifiable information.  Furthermore, parents agree that their child is the person completing the baseline test, he/she is reasonably well-rested and in good health and that the session will occur in a suitable test environment that is free from distraction. 


I understand that my consent may be revoked at any time by contacting us by email at

YOU MUST HAVE THE PROPER CLINIC CODE BEFORE PROCEEDING - contact Dr. Czarnota ( if you do not have the code or did not received the code from your team/school. 

I have read and understand the information set out above and have had the opportunity to ask questions. I affirm that I am of the age of consent or am the adult parent/guardian and able to make such decisions on behalf of the minor/athlete. By clicking Agree I give my consent to participate in the Concussion Safety Program, including ImPACT testing, and further consent to the collection, use and disclosure of my personal information as set out above.



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