TBI Northwest programs are designed to empower clients to incorporate brain and body performance training into their everyday lives. It is our perspective that prevention and maximum performance are superior to simply symptom resolution.

Note when participating in any TBI Northwest body and brain performance program, in contrast to a recovery care program with one of the doctors, it does not constitute medical care and it should not be considered a substitute for ongoing primary or specialty care when needed.

Please read the following and sign below to affirm your understanding of, and consent to, the following:

1. I understand that some of the tools and strategies offered during the course of my participation may involve the use of new methodologies and equipment that have not been evaluated by the U.S. Food and Drug Administration.
2. I understand that there are cameras, that may be on, in the exercise room for documentation purposes and liability reasons.
3. I give permission for the submission of video clips of my training or home instruction via email or text.
4. I understand that change rooms are available and that shorts, a t-shirt, and running shoes are recommended.
5. I understand that make-up, mascara, etc., interfere with some of the diagnostics and should be avoided.
6. I understand that the evaluation may include physical contact that may be considered sensitive to some individuals. Questioning and voicing concerns are encouraged.
7. I understand that it is my right to refuse any form or aspect of the evaluation prior to or during the evaluation for whatever reason.
8. I understand that if for whatever reason I am uncomfortable about doing an evaluation prior to or during, I can suspend and reschedule the evaluation or a portion of the evaluation to a future date.
9. I understand that it is my right and my choice to have a chaperone in the room during my evaluation.
10. I understand that some aspects of training or data acquisition may be provided by assistance with no specific medical training but that the data will be reviewed by a trained professional.
11. I understand that no medical notes, nor fee slips, will be provided for any performance training, group training, group functional assessments, or for any services not scheduled specifically as rehabilitation.
12. I understand that TBI Northwest “performance training” services are NOT medical care and may be managed by personal trainers rather than medical staff.
13. I understand that if treatment of a condition and medical notes are desired that the visits need to be scheduled as an “hourly visit” and no other plan or program. This does not mean, however, that fees or notes will be submitted on behalf of the client. Nor will anyone communicate with the adjusters of major medical insurance companies. It is the responsibility of the client to manage their insurance and benefits.
14. I understand that the focus of this company and its services revolves primarily around physical and brain performance and not a specific treatment of a condition or disease unless specifically stated and scheduled for private 1 on 1 medical evaluation and rehabilitation.
15. I further understand that with this focus on performance in mind, the providers/trainers of this facility will be intent on identifying relative weaknesses of functional integrity and facilitating greater health or performance which may or may not result in changes in symptoms. Outcomes are not, and cannot be guaranteed.
16. I understand that all group and performance evaluations and training are not intended to treat or cure any condition or disease.
17. Other than services under motor vehicle insurance, I understand that all fees will be prepaid prior to service being provided.
18. I understand that fees can be changed with written or posted notice.
19. I understand that there are no refunds for memberships, purchased training hours, or evaluations.
20. I am giving permission to send notes or reports when requested by fax or email.
21. I am giving permission to release health information to my health care providers when requested by fax or email?
22. I am giving permission for you to leave voicemail messages, texts, or email messages?
23. [VERY IMPORTANT] - Charges billed to the patient/guardian following insurance processing, may accrue interest in accordance with state law. This will not apply if payment arrangements are coordinated within 30 days.
24. You will only receive a patient billing after all other options are exhausted. I understand that by consenting to treatment, I am authorizing the use of information provided to collect payment for medical services in accordance with state laws.
25. You can visit the TBI Northwest Policy Center to read our Terms & Conditions & User Disclaimer.
26. NOTE: The only insurance we process is PERSONAL INJURY PROTECTION. Any remaining balance will be held with a letter of protection that both client and attorney sign in advance of any care.