PEMF Consent Form
Name
*
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I acknowledge that there are 2 different applications of the High-Intensity Pulsed Electro-Magnetic Fields (PEMF) and that implementation of which application is best will be determined on a time-by-time basis (loops and/or mats):
*
Yes.
No.
Please list ALL current daily medications, herbs and/or supplements and dose:
CONTRAINDICATIONS:
*
Pregnancy / breastfeeding.
Breast implants.
Epilepsy and/or seizures.
Heart conditions e.g. heart failure, heart blockages, recent heart attack, arrhythmias, etc.
Elevated blood alcohol or drug levels
Active bleeding / bleeding tendency i.e. bleeding wound, menstruation, hemophilia.
Electrical implants e.g. pacemaker, cochlear implant, intrathecal pump, insulin pump, etc.
Organ transplant patient, i.e. taking immune suppression medication.
Implanted metals e.g. pins, plates, screws, joint replacements, mechanical heart valves, metal stents, staples in blood vessels, etc.
Grave's disease.
None
Explain the CONTRAINDICATIONS marked above:
Do you have any other medical conditions that the staff / practitioner / technician should be aware of?
*
Please check the box to acknowledge you have read and understand:
Submit
Should be Empty: