BASELINE ASSESSMENT TEST AND POST-INJURY TESTING AND RELEASE OF INFORMATION
I hereby agree and consent to have my child undergo a
baseline assessment test, and any post- injury tests as well, utilizing the
Motion Intelligence ClearEdge test. I further hereby agree and
consent to allow Motion Intelligence to release any baseline and post-
injury test results to my child’s primary care physician, neurologist, or other
treating physician or care provider if necessary.
I understand that the purpose of the initial testing is to
establish a baseline of cognitive and balance functionality which may be
compared to future testing if my child sustains a suspected injury. I understand that the Motion Intelligence
ClearEdge test will provide this baseline neurocognitive and balance
assessment, and will provide significant data for return to play, return to
work, or return to duty decisions, to be used in conjunction with a physical
examination and other diagnostic testing. I understand that Motion
Intelligence does not make any return to play, work or duty
decisions. I understand that return
to play, work or duty decisions should only be made by a qualified physician,
neurologist or other health care professional.
I understand that my child’s baseline and
post-injury tests results will be retained (stored) electronically by Motion
Intelligence. I understand that the baseline and post-injury test results
are confidential and may only be accessed by myself, my child, and those
directly involved in the treatment or management of my child.
understand that the test results and data collected may be used by Motion
Intelligence in the aggregate for purposes of identifying trends in testing
results, improving the effectiveness of the test, the correlation of the
ClearEdge data with certain characteristics of athletic performance, and better
understanding the nature of the injury. All personal identifying information
will be removed for these purposes.
I have read and fully understand this Consent Form. I have
been given an opportunity to ask questions, and all of my questions have been
answered to my satisfaction. I know that Motion Intelligence maintains a
I may review at any time.