Injury Report

This form is to be submitted by Athletic Trainers providing medical coverage of OrthoCincy affiliated events. All required fields must be filled out prior to submitting.

Patient Name

Patient Date of Birth

Parent/Guardian Name (if applicable)

Phone Number

Date of Injury

Injury Type/Body Part (specify Left or Right, if applicable)

Pertinent Physical Exam Findings and/or Additional Information

Event Name

Level of Play

Athletic Trainer Name

Athletic Trainer's Employer/Organization