Clinic Intake Form

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Reason for Visit/Goals

How Did You Hear About Us

Please read the following questions and honestly answer each one by checking

Do you have a heart condition?(Required)

Yes

Have you been told to limit physical activity because of the heart condition?(Required)

Yes

Do you ever feel pain in your chest when you perform physical activity?(Required)

Yes

In the past month, have you had chest pain when you were not performing any activity?(Required)

Yes

Are you currently taking prescribed medications for any chronic medical condition?(Required)

Yes

Have you been hospitalized in the past 10 years?(Required)

Yes

Is there a chance you may be pregnant?(Required)

Yes

Do you have cancer?(Required)

Yes

Do you have a pacemaker?(Required)

Yes

Have you had any issues with blood clots in the previous 12 months?(Required)

Yes

Do you have a history of losing consciousness; fainting or syncope?(Required)

Yes

Has your physician told you to limit physical activity for any health-related reason in the past year?(Required)

Yes

Have you ever had any kidney problems, including rhabdomyolysis?(Required)

Yes

Are you aware of any other reason why you should not engage in physical activity?(Required)

Yes

If 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:

1. ASSUMPTION OF RISK:(Required)

I understand that the Services at NeuFit involve the use of the FDA-cleared Neubie® device, various forms of manual therapy, and physical exercises. I acknowledge and accept that these activities involve certain inherent risks, including, but not limited to:

Physical Injuries: Engaging in any physical activity, including at NeuFit, carries the risk of injuries, diseases, disabilities, and even death.

Skin Irritation: Use of the Neubie may lead to redness of the skin, or skin irritation like stinging or burning.

Cardiovascular Issues: Rigorous physical activity, including that performed at NeuFit, challenges the cardio-vascular system. There are risks of heart-related problems, like heart attack and irregular heart rhythm.

Muscle Soreness: The Neubie can create more strain on muscles than a typical workout, which may lead to muscle soreness, fatigue, and longer recovery time.

Kidney-Related Conditions: Higher muscle strain may also create more muscle breakdown than a typical workout, increasing the risk of kidney-related conditions like rhabdomyolysis, especially when combined with other factors such as dehydration, consumption of alcohol, additional exercise outside of NeuFit, and various health conditions. I understand that, if I experience any symptoms of rhabdomyolysis (muscle pain, muscle stiffness, extreme weakness, severe fatigue, change of urine color, decreased urine output, altered mental sadness, swelling and/or pain), I should immediately cease all physical activity and admit myself into a hospital for monitoring and treatment. I acknowledge that NeuFit service providers will not be able to monitor whether I am experiencing symptoms of rhabdomyolysis and that it is my responsibility to monitor my own symptoms and seek medical treatment as needed.

Personal Privacy: 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.

2. RELEASE AND WAIVER OF LIABILITY:(Required)

I agree not to hold NeuFit or any of its owners, representatives, employees, or associates responsible for any injuries, illnesses, or damage that might occur due to my participation in the Services, even if caused by their negligence or gross negligence.

3. FEES:(Required)

I understand that the Services from NeuFit may not be covered by insurance, and I agree to pay for these Services at the time of my visit. I also understand that NeuFit may charge me the full amount of any canceled or missed appointments if I do not notify NeuFit of my intent to cancel within at least 24 hours of that appointment.

4. DISPUTE RESOLUTION:

If there is a dispute related to these Services or this Agreement, I agree to resolve it through arbitration before the American Arbitration Association in Austin, Texas, and that Texas law shall govern any such dispute. Each party shall bear its own costs of arbitration.

5. IMAGE RELEASE:(Required)

I give permission for NeuFit to use my image in photos or videos for their printed and digital publications, including website and social media.

6. VALIDITY & BINDING EFFECT:(Required)

If any part of this Agreement is found to be legally invalid, the rest of the agreement still applies. This agreement also applies to my personal representatives, successors, and assigns.

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.

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Clinic Intake Form

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