York County PEMF LLC Small Animal Intake and Consent Form
Date
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Month
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Day
Year
Date
Type of Animal
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Animal's Name
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Animal's Weight
Animal's Age
Your Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have your animal ever had PEMF therapy?
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Yes
No
If yes, for what?
Your animal is not a suitable candidate for PEMF if any of the below apply. Check every box if the condition does not exist.
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My animal is NOT pregnant: Pregnant animals should avoid PEMF therapy as its effects on fetal development are not wellunderstood.
My animal does NOT suffer from seizure disorders: Animals with a historyof seizures or epilepsy should avoid PEMF therapy, as it could potentiallytrigger seizures and the research does not provide adequate informationsupporting its use in these cases.
My animal does NOT have an acute infection: PEMF therapy may not be suitable for animals with acute infections, as it could potentially worsen the condition by stimulating the immune system.
My animal is NOT colicing: Colic is a general term for abdominal pain in animals that can be caused by a number of issues, including gastrointestinal, urinary, reproductive, and respiratory problems. PEMF should not be used if your animal has colic or is undergoing colic treatment.
My animal does NOT have any implated devices: PEMF can interfere with some electrical medical implants, so you should consult yourveterinarian before using PEMF on an animal with any implants. Microchips are not affected by PEMF.
Reason for seeking out PEMF for your animal. Please be as specific and detailed as possible and list any areas of concern.
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Brief animal's history of any surgeries, illnesses, or medical issues:
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Animal's Daily activities (work, exercise, wellness regimen):
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Detoxification
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Natural bodily responses of detoxification that may occur during and after an animal’s Pulse session may include coughing, sneezing, vomiting, diarrhea, light-to-moderate sweating, appearance of waxy skin or hair, coat purge and regrowth. Every animal responds differently, so it is important to keep the veterinarian informed as Pulse sessions progress.
Consent
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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. I understand that I am responsible for ensuring my animal is medically cleared by a licensed veterinarian 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:
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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
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