York County PEMF LLC Human Intake and Consent Form
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Please Select
Male
Female
Uncomfortable answering
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had PEMF done on you before?
*
Yes
No
Know someone who has
Have an animal that has
Contradictions to Treatment
*
Do not use PEMF if you have an implanted electronic device (e.g., pacemaker, defibrillator, insulin pump), are pregnant or may be pregnant, are actively bleeding, have had an organ transplant, or have untreated injuries not evaluated by a licensed healthcare provider.Please click to acknowledge these do not apply.
Reason for seeking out PEMF. Please be as specific and detailed as possible and list any areas of concern.
*
Rate your currently level of comfort 1 being the most comfortable 5 being unbearable.
*
1
2
3
4
5
Brief history of any surgeries, illnesses, or medical issues:
*
Daily activities (work, exercise, wellness regimen):
*
List of Medications
*
Please include supplements that you may be taking, if you do not take medication or supplements, write N/A
Hydration Reminder
*
Staying well-hydrated before and after your York County PEMF session is essential. Water helps flush toxins from the body and supports your natural detox systems—like the liver, kidneys, and lymphatic system. Detoxing too quickly can overwhelm these systems, sometimes causing temporary symptoms like fatigue, flu-like feelings, or skin irritation. These reactions are usually short-lived, but if they persist, consult a healthcare provider. Drinking plenty of water and using supportive supplements can help ease the process. Please click to acknowledge.
Consent
*
PULSE PEMF is not a medical device and is not approved by the FDA or NDF. It is not intended to diagnose, treat, cure, or prevent any medical condition. All information provided is for educational purposes only and should not replace professional medical advice. By choosing to use York County PEMF services, I acknowledge and accept all associated risks, including potential injury or worsening of existing conditions. While rare, possible side effects may include breathing issues, fainting, cramps, or other medical events. This list is not exhaustive. I understand that I am responsible for ensuring I am medically cleared by a licensed healthcare provider and for informing staff of any health changes before each session. I also authorize York County PEMF to seek emergency medical care if needed and accept responsibility for any related costs. By proceeding, I release York County PEMF and its affiliates from any liability and confirm my voluntary participation. Please click to acknowledge.
Please click to acknowledge and sign below:
*
I understand that these services are not a substitute for medical care, and any advice provided is for educational purposes only. I confirm that the information I’ve provided is accurate, that I am 18 years or older, and that I accept all risks associated with participating in these services. Please click to acknowledge.
Signature
*
Continue
Continue
Should be Empty: