Healthcare Biomechanical Consent Form

Healthcare Biomechanical Consent Form

Patient Information

Patient Name:    Date of Birth:

Female    Male    Other   

Insurance Information

Medical History

Procedure Description

Description: The biomechanical assessment may include motion capture, three-dimensional kinematic analysis, force plate assessment, electromyography (EMG), physical examination and functional testing, and video recording for clinical review. The purpose is to evaluate movement, muscle activation, joint loading, and functional patterns to inform diagnosis, treatment planning, or device fitting.

Risks, Benefits and Alternatives

Potential benefits include improved diagnostic information, targeted treatment planning, and objective outcome measurement. Potential risks and discomforts include, but are not limited to, the following:

Skin irritation or minor abrasions from sensors/electrodes or adhesive tapes.
Bruising at sensor or marker placement sites.
Temporary muscle soreness or fatigue following testing.
Possible transient increase in pain or symptom provocation during functional tests.
Allergic reaction to adhesives or conductive gels.
Measurement error or inconclusive results due to movement artifact, clothing, or equipment limitations.
Other:

Patient Responsibilities & Preparations

To ensure accurate assessment, the patient agrees to the following as applicable:

Wear comfortable, form-fitting clothing or clothing as instructed.
Avoid lotions, oils, or powders on skin areas where sensors will be placed.
Remove jewelry and removable prosthetics as instructed.
Inform assessor of medications taken within 24 hours that may affect performance.
Additional instructions:

Privacy, Data Use, and Authorization

I authorize collection of my protected health information (PHI) and biomechanical data (including motion capture, video, EMG signals, force measurements, and derived reports) for the purpose stated above. This data may be used for clinical care, billing, device fitting, internal quality improvement, and with my additional consent, for research and educational purposes. When used for research or publication, identifiable information will be removed unless I provide separate written consent to be identified.

I understand that this information may be disclosed to other clinicians involved in my care and to third-party payors as necessary for billing. The holder of my records will take reasonable steps to protect confidentiality but cannot guarantee absolute privacy with electronic data. I may revoke this authorization at any time by providing a written notice to the issuing facility; however, revocation will not affect disclosures already made in reliance on this authorization.

I acknowledge that I have read and understand the privacy practices described above and authorize release and use of my biomechanical data as indicated.

This authorization expires on or upon earlier written revocation.

Voluntary Consent

I have had the opportunity to ask questions about the biomechanical assessment, its purposes, expected benefits, and potential risks. All my questions have been answered to my satisfaction. I understand that I may withdraw my consent at any time before or during the assessment without penalty and that withdrawal will not affect my right to future care.

I voluntarily consent to undergo the biomechanical assessment described above and to the collection, use, and disclosure of my data as described in this form.

I consent to audio and/or video recording during the assessment for clinical documentation and teaching with removal of direct identifiers as appropriate.
I do not consent to audio/video recording.

I consent to the use of my de-identified biomechanical data for research, publication, or educational presentations.
I do not consent to the use of my data for research or education.

Acknowledgment and Certification

By signing below I certify that I am the patient or authorized representative and that I have read or had read to me the information in this form, understand its contents, and consent to the procedures and data uses described. I understand that signing this document constitutes an informed consent for the specified biomechanical assessment.

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