Human PEMF Intake & Consent Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number

What type of session would you like? *

Reason for session*

Are you pregnant or breastfeeding?*

YesNo

Please check if you have any of the following:*

Do you have high or low blood pressure?*

YesNo

Have you had surgery resulting in the placement of metal implants?*

YesNo

I have or had cancer*

YesNo

If yes, what was the diagnosis? And are you currently receiving treatments?

List any other medical conditions or surgeries, or any other wellness/alternative therapies you are participating in.

If yes, please specify on the field above.

Sports or activities you participate in

Anything you would like to add

I hereby state that I am at least 18 years of age and have read, understand and agree to this Release Statement, that it is an informed release and that I intend to be legally bound by it.

» I am not pregnant
» I have no pacemaker or other battery operated implanted stimulator
» I have not had an organ transplant
» I do not have any chains on me (jewelry is OK)
» I do not have any car key, credit card, cell phone or watch on me
» I agree to be fully responsible for any damages if I forget this
» I know that I am using a magnetic pulse generator that is not approved by the FDA to treat or cure any disease or condition
» I understand that this is an experimental device

No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind.

I release from all general, medical and any other liability or claims of any kind; and,
I indemnify and hold harmless the MagnaWave magnetic pulse generator, the manufacturer, distributor, dealer and any of their employees or agents from any claim arising from or related to my use of the magnetic pulse generator.

Printed Name of Client

First NameLast Name

Signature of the Client*

Clear

Date Signed*

Date

PEMF Intake & Consent Form

Client Information

Consent and Waiver