DWT Wellness Health Consent & Release Form Logo
  • Health Intake & Release Form

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  • 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 to it. 

    >> I am not pregnant

    >> I do not have a pacemaker, cochlear implant, or other battery operated implanted stimulator

    >> I have not had an organ transplant

    >> I am not currently undergoing any cancer related treatments

    >> I have removed any car keys, credit cards, cell phones, or watches

    >> I agree to be fully responsible for any damages if I forget to do this

    >> I agree that 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 Aura and/or 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 a magnetic pulse generator.

    I grant media release permission for my likeness or image to be used in a variety of media, including photographs, videos, and audio recordings.  I waive any right to compensation for the use of their image or likeness. I also waive my right to inspect or approve how my image or likeness is used.

    By submitting this form, I agree to the terms listed on the session and media release waiver.  Lastly, I am opting in to receiving promotional and/or follow up text messages.

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