York County PEMF LLC Human Intake & Consent Form
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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
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 including but not limited to a pacemaker, defibrillator, cochlear hearing device, spinal stimulator, glucose monitor, or insulin pump, if you are pregnant or believe you may be pregnant, if you are actively bleeding or hemorrhaging, if you are the recipient of an organ transplant, or if you have injuries or concern of injuries that have not been evaluated by a licensed health care 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
Detoxification
*
It is crucial to drink plenty of water before, after, and throughout the day following a York County PEMF session. Water helps flush toxins from the body. Detoxifying too quickly, especially with high toxin levels, can overload the body’s elimination systems—such as the kidneys, liver, colon, lymph, skin, and lungs. Overloading these systems may lead to a detox reaction or “healing crisis,” causing flu-like symptoms or skin rashes. While these are signs of detox, if they persist, seek medical advice. Supporting your body’s elimination with water and supplements helps ease detox reactions, which often pass quickly when organs function properly. Please click to acknowledge
Consent
*
PULSE PEMF is not a medical device and has not been evaluated or approved by the FDA or NDF, and we do not claim it is intended to treat, cure, prevent, or diagnose any disease or medical condition. The information provided is for educational purposes only and should not replace professional medical advice. York County PEMF cannot be held liable for any new or existing conditions or their worsening. I voluntarily choose to use York County PEMF’s services, which may include certain applications mentioned above. I understand the risks involved and acknowledge that despite efforts to minimize them, some risks are inherent and cannot be fully eliminated. I am aware that injuries, though rare, may include breathing issues, stroke, bleeding, convulsions, unconsciousness, fainting, cramps, or sudden illness. This list is not exhaustive, but I acknowledge that I understand the potential risks.I authorize York County PEMF and its representatives to consent to any necessary medical or hospital care if needed due to my participation in the services. I accept responsibility for any associated medical costs.By requesting these services, I acknowledge and accept all risks, including loss, damage, injury, illness, death, or worsening of any pre-existing condition (known or unknown). I release York County PEMF, its manufacturer, distributor, officers, employees, and agents from any liability related to these risks.I also take responsibility for ensuring I am medically cleared by a registered healthcare provider before engaging in these services and for informing staff of any changes in my medical condition before each session. Please Click to acknowledge.
Please click to acknowledge and sign below:
*
I understand that the services received are not a substitute for medical care and any information and/or advice given by the staff / practitioner / technician is for educational purposes only.I confirm that the information contained herein is true and accurate and proceeding with the engagement of the services is done at my own risk.I confirm that I am 18 (eighteen) years of age or older and that I have read and understood the contents hereof.
Signature
*
Continue
Continue
Should be Empty: