CIC Application

Fill out this 2-minute application below and we’ll be in touch.

Country*
If your country is not listed you are not eligible for the CIC program.
Name*
First Last
Title*
Eligible Professions in the US: MD, DO, PhD/PsyD, PA, NP. If your title is not listed, you are not eligible for the CIC program.
Title*
Eligible Professions Outside US: Any healthcare provider outside of the US who is qualified to manage concussions may apply.
Email*
Name of Organization/Clinic*
Address*
Street Address Address Line 2 City ZIP / Postal Code
State*
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NoState - Hidden
Province / Region*
Phone number where you can be reached*
Are you a current ImPACT Applications customer, or are you affiliated with an organization that utilizes ImPACT Applications?*
- Yes
- No
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Send me information on training programs to build my multi-disciplinary concussion management team.
- Yes
We reserve the right of sending periodic communications from ImPACT Applications.
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User ID

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