Client Intake Form

Vantage PEMF Therapy

Client PEMF Intake Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday

MonthDayYear
Date
Please list any medications you are taking, including supplements.
Please provide a brief history of surgeries and relevant dates. (Type “none” if no surgical history).
Please select any of the following that apply to you.
Explain any conditions you have marked above.
Are there any other conditions not listed above? If so, explain.
Are you currently pregnant?
Are you a recipient of an organ transplant?
Do you have an implanted electronic device? (example: pacemaker or cochlear).
Have you had PEMF before?
What goals do you have for your PEMF Session?
By clicking below, I understand that this PEMF session is not a replacement for medical care and that no diagnosis will be made.
By clicking below, I understand that Vantage PEMF Therapy has a 24 hour cancellation policy. If I cancel or reschedule my session within 24 hours of my reserved time, I will be billed 50% of the amount of the session.
I consent to allow Vantage PEMF Therapy to take photos or video during my session for marketing, training, or social media purposes.
How did you hear about Vantage PEMF Therapy?

Other
If someone referred you, please list their name below.
Please add any additional information that will help prepare for your PEMF Session.
Informed Consent

Liability Release
The undersigned agrees to the terms and conditions set forth in this document. I have carefully read this document and fully understand its contents. I AM AWARE THAT THIS IS A CONTRACT BETWEEN MYSELF AND VANTAGE PEMF THERAPY AND CONTAINS AN ASSUMPTION OF RISK AND A RELEASE OF LIABILITY FOR MYSELF AND MY PROPERTY, INCLUDING ANIMAL USERS, AND I SIGN IT OF MY OWN FREE WILL. By signing this release, I certify that I am eighteen (18) years of age or older - or have delivered the consent of my parents or guardian to Vantage PEMF Therapy. By signing, I have acknowledged that the Certified Pulse PEMF Professional may need to adjust the Pulse accessories on my or my animal's body and hereby give them permission to touch and assist in adjusting my or my animal's body as needed.

By signing below, I, the undersigned, am agreeing to all above terms and the contents in the above document.
PEMF for Minors

Vantage PEMF Therapy require’s a parent or guardian’s consent and presence for minors aged 18 or younger.
By signing below, I agree that all the information above is true, and agree to the above terms.
Should be Empty:

Vantage PEMF Therapy

Informed Consent

PEMF for Minors