Clinic Intake Form 1Client Information2Waiver and Release of Liability3Acknowledgement of Coronavirus RiskName(Required)Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Emergency Contact Name(Required)Emergency Contact Phone(Required)Reason for Visit/GoalsHow Did You Hear About UsPlease read the following questions and honestly answer each one by checkingDo you have a heart condition?(Required) Yes NoHave you been told to limit physical activity because of the heart condition?(Required) Yes NoDo you ever feel pain in your chest when you perform physical activity?(Required) Yes NoIn the past month, have you had chest pain when you were not performing any activity?(Required) Yes NoAre you currently taking prescribed medications for any chronic medical condition?(Required) Yes NoHave you been hospitalized in the past 10 years?(Required) Yes NoIs there a chance you may be pregnant?(Required) Yes NoDo you have cancer?(Required) Yes NoDo you have a pacemaker?(Required) Yes NoHave you had any issues with blood clots in the previous 12 months?(Required) Yes NoDo you have a history of losing consciousness; fainting or syncope?(Required) Yes NoHave you been cleared by your physician for physical activity?(Required) Yes NoHave you ever had any kidney problems, including rhabdomyolysis?(Required) Yes NoAre you aware of any other reason why you should not engage in physical activity?(Required) Yes NoAre you aware of any other reason why you should not engage in physical activity?(Required) Yes NoIf you answered ‘YES’ to any of these questions, please provide additional explanation:In receiving rehabilitation and/or fitness services from Neurological Fitness and Recovery Facilities LLC (“NeuFit”), located at 2501 S. Capital of Texas Hwy, Austin, TX 78746, I, agree as follows: (please check each box and sign at the bottom)ACKNOWLEDGEMENT OF RISK: I understand that my session(s) at NeuFit involve the use of the FDA-cleared Neubie® device in combination with various movements, exercises and/or techniques of manual therapy. The service providers at NeuFit have been trained in the safe and eective use of the Neubie and other techniques being used. Nevertheless, I acknowledge that there are inherent risks associated with these activities, including but not limited to the following:Acknowledgement(Required) My participation in any physical activity, including at NeuFit, carries the risk of bodily injury, disease, disability, and death; Use of the Neubie may lead to redness of the skin, or skin irritation like stinging or burning; Performing rigorous physical activity, including that performed here at NeuFit, challenges the cardio-vas- cular system. If the cardio-vascular system is compromised or cannot keep up with the challenges of this activity, there are risks of various cardio-vascular issues or problems, like heart attack and heart arrhythmia; Because the Neubie can create more load on muscles than is experienced in a typical workout, it often allows us to make more progress in a NeuFit session than in a traditional therapy or fitness session. For that same reason, using the Neubie may also lead to muscle soreness, fatigue, and a need for increased recovery time; That additional load on the muscles may also create more muscle breakdown than a typical workout. When the byproducts of muscle breakdown enter the bloodstream, the organs have to process them. If enough of these byproducts build up in the blood, especially when combined with dehydration, impaired organ function, participation in additional exercise outside of NeuFit, or other stressors or health challenges, it may increase the risk of kidney-related conditions like rhabdomyolysis.Select AllConsent to Receive Services(Required) I fully understand and acknowledge the risks listed above and hereby assume all of those risks. As such, I hereby consent to receive rehabilitation, recovery, and/or fitness training services from the providers at NeuFit. Because of the nature of services provided, I understand I may at times have electrodes placed on sensitive areas of my body and that the NeuFit service provider may perform manual techniques requiring physical touch. I know that the sta is committed to upholding my privacy, modesty, and dignity, and that if I ever feel uncomfortable with what I’m being asked to do that I may refuse the procedure, stop the procedure, and/or request to work with another provider.Release of Liability(Required) I, on behalf of myself, my personal representatives and heirs, hereby voluntarily agree to release, waive, and hold harmless NeuFit, and NeuFit’s owners, representatives, employees, providers, advisors, and assigns from all liability for any services rendered. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for negligent acts or other conduct by any representatives or employees of NeuFit.Neufit Fees(Required) I understand that NeuFit Services are not covered by my medical insurance. I acknowledge that I am responsible for any and all fees incurred for these services at the time of my visit, and I am fully aware of the amount of those fees. I also understand that I am responsible for payment of the fee for canceled sessions if I fail to notify NeuFit of the cancellation at least 24 hours in advance.Image Release I understand that, from time to time, pictures or videos may be taken of the work that is going on at NeuFit and shared for marketing or educational purposes. I hereby grant NeuFit permission to use my likeness in video or photograph for its printed and digital publications, including social media platforms. I waive the right to inspect or approve the finished product, and waive the right to any compensation arising out of the use of my likeness in any videos or photographs.I understand that there is currently an elevated risk of being exposed to the Coronavirus (the “virus”) in any public places and during any in-person interactions with any other person, including at the NeuFit facility or by working with any NeuFit providers who are performing mobile sessions. Although the service providers at NeuFit are following CDC guidelines for hygiene and making commercially reasonable efforts to minimize the risk of exposure to the virus (such as consistent handwashing, wiping surfaces that are touched during any session, etc.), it may, however, be impossible to fully prevent exposure to the virus.In consideration for my participation in any sessions at the NeuFit facility or any mobile NeuFit sessions, I understand that there may be a risk of virus exposure at NeuFit or in performing any mobile NeuFit sessions. I am willing to assume the risk of such exposure, and will not hold NeuFit liable for any exposure that occurs due to my sessions at the NeuFit facility or any NeuFit sessions performed outside of the facility (like mobile sessions at my home), or the resulting illness from such exposure. In addition, I pledge that, I will notify NeuFit if I am showing any signs of respiratory illness or fever, or if I have been told by a medical professional to be quarantined, or if I have knowingly come in contact with someone showing signs and symptoms and/or diagnosed with COVID-19.In addition, if any of these events occur, I will not participate in my NeuFit session in order to reduce the risk of exposure for others. During this period of federally-declared National Emergency, the typical 24-hour cancellation policy is being relaxed, so I can cancel my session without fear of forfeiting credit for my session.Type your nameΔ
