Microcurrent Consultation Form
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you over age of 18?
*
yes
no
Your Health
Have you experienced any of these health conditions in the past or present?
*
active cancer / suspicious or cancerous legion
epilepsy / seizure
recent surgery or other surgical procedure
swollen, infected, inflamed area or skin eruption i.e. phlebitis, thrombophlebitis, broken capillaries, varicose veins
none
Do you?
*
have body piercings
have a metal plate
have a pacemaker
have an electronic implant such as defibrillator, neurostimulator or ECG Monitor
no
Do or have you?
*
use a body worn medical device such as insulin pump
been under the care of a physician
have any pre-existing or potential health conditions that may be impacted by use of the device
have painful areas
been diagnosed with or suspect a neuromuscular disorder
have a spinal cord injury
have any underlying skin conditions
have undiagnosed or known pain syndrome
have a tendency to bleed excessively following an injury
experience constant headaches and/or painful sensations
been diagnosed with or suspect heart disease
no
Have you?
been diagnosed with or suspect a thyroid problem
used topical or systemic steroids
had skin sensitivity to light or used medications that cause skin sensitivity to light
Other
Female Clients
Are you pregnant?
*
yes
no
recently had a baby
Signature
*
Submit
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