It is our policy that a licensed physician (MD) completes this form.
We cannot accept a signature from a Physician’s Assistant (PA) or
a patient care assistant (PCA) or any other non-physician providers.

Medical Release Form

Your patient has expressed interest in participating in our program. Bridging Bionics Foundation (BBF) requires your medical clearance to confirm that the patient is physically capable of participating in our physical therapy interventions and can safely use our equipment and technology. Some of the neuro-rehabilitation equipment used in our program have multiple contraindications and involve a level of inherent risk, and we want to ensure your patient's safety.

Our Mobility Program

The interventions employed by the program fit into four (4) categories:

  1. Physical Therapy – Functional movement maintenance and/or enhancement. Clinical expertise, clinical decision-making and critical thinking to determine who can qualify to use a variety of advanced technologies.
  2. Performance Training – individual and small group
  3. Whole Body Vibration technology
  4. Gait Rehabilitation Assistive Technology: Exoskeleton or Robotic

Bridging Bionics Foundation utilizes the following therapeutic technologies as part of our mobility program. Note, this is a partial list highlighting our primary advanced technologies.

  • Galileo side-alternating whole-body vibration devices (platform, tilt table, and dumbbell) (https://galileousa.com)
  • Lokomat – a robotic assisted gait training device (https://www.hocoma.com/us/solutions/lokomat/)
  • Ekso GT™ - a wearable robot or exoskeleton that enables people with lower-extremity paralysis or weakness to stand and walk (https://eksobionics.com)
  • Ekso Indego Therapeutic Device – a wearable exoskeleton used in a clinical setting (https://eksobionics.com/ekso-indego-therapy/)
  • Keeogo Dermoskeleton - a walking assistance device or smart powered orthosis for rehab use (https://keeogo.com)
  • KineAssist MX™ walking and balance system – a harnessed treadmill that will support and prevent falls.
  • Neubie by NeuFit - The Neubie, short for ‘Neuro-Bio-Electric,’ is an innovative, FDA-cleared device that utilizes direct current (DC) to foster tissue healing and neuromuscular re-education. (https://www.neu.fit)
  • Blood Flow Restriction Training
  • Functional Dry Needling

Examples of some of the equipment used in our program

GALILEO PLATFORM GALILEO PLATFORM
GALILEO TILT TABLE GALILEO TILT TABLE
EKSO GT EKSO GT
KEEOGO LOKOMAT NANOS
Patient Information

Does this patient use any of the following aids or assistive devices? (Please choose below)

Before a physical therapy plan is established, a good knowledge of the patient’s physical condition and possible risks must be assessed. Following is a list of contraindications that might exclude an individual from using one or more technologies in our program. Please check if your patient experiences any of the following conditions and provide additional details if necessary.

** Please attach your patient’s list of medications **

After medical clearance, each patient will be evaluated by one of our skilled physical therapists to ensure they are a suitable fit for a particular device or physical therapy intervention.

, has my permission to take part in Bridging Bionics Foundation’s mobility program with the restrictions and/or recommendations stated below.

Please identify any recommendations, precautions, or restrictions that are appropriate for your patient:


Additional Information

If you have questions regarding our technologies and therapeutic mobility program, please contact:

Maria Grufstedt, Physical Therapist and Clinical Leader

Bridging Bionics Foundation

maria@bridgingbionics.org

You may also call our business cell phone at (970) 379-0721.