Clearedge - Patient Rapid Registration Form

Account Information

This section for the ClearEdge account holder, who manages information for one or more patients. You can add yourself or your child as a patient below.

First Name *

Last Name *

Email *

Confirm Email *

I am at least 18 years old *

Basic Patient Information

This section is for the individual being tested. You can add additional patients later.

Relationship to Account Holder *

First Name *

Last Name *

Street Address 1 *

Street Address 2

City *

State *

Zip *

Sex *

Date of Birth *

Enter height/weight in ... *

Height *

feet

inches

Weight *

pounds

Terms and Conditions

MOTION INTELLIGENCE

CONSENT FOR 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.

I 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 Terms of Use and Privacy Policy on its website at www.motionintel.com that I may review at any time.

I agree to the above terms. *