CONSENT FOR BASELINE ASSESSMENT TEST AND POST-INJURY TESTING AND
RELEASE OF INFORMATION
I hereby agree and consent to undergo a baseline assessment
test, and any post- injury tests as well, utilizing the ClearEdge test. I further hereby agree and consent to allow Motion Intelligence to release any
baseline and post- injury test results to my 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 I sustain 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 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 me and those directly involved in my treatment or management.
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
www.motionintel.com that I may review
at any time.