York County PEMF LLC Equine Intake & Consent Form
Date
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Month
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Day
Year
Date
Horse's Name
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Horse's height in hands
Horse'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.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have your horse ever had PEMF therapy?
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Yes
No
If yes, for what?
Your horse 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 mare is NOT pregnant: Pregnant mares should avoid PEMF therapy as its effects on fetal development are not well understood.
My horse does NOT suffer from seizure disorders: Horses with a history of seizures or epilepsy should avoid PEMF therapy, as it could potentially trigger seizures and the research does not provide adequate information supporting its use in these cases.
My horse does NOT have an acute infection: PEMF therapy may not be suitable for horses with acute infections, as it could potentially worsen the condition by stimulating the immune system.
My horse is NOT colicing: PEMF should not be used if your horse has colic or is undergoing colic treatment.
My horse does NOT have any implated device: PEMF can interfere with some electrical medical implants, so you should consult your veterinarian before using PEMF on a horse with any implants. Microchips are not affected by PEMF.
Reason for seeking out PEMF for your horse. Please be as specific and detailed as possible and list any areas of concern.
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Horse's brief history of any surgeries, illnesses, or medical issues:
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Horse'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 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:
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I understand that the services received are not a substitute for medical care and any information and/or advice given by the staff / practitioner 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
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