Human Intake Form

Human Intake Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Number*
Email Address*
example@example.com
How would you like to be contacted?*

TextPhone CallEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you're filling out this form on behalf of a minor, their name is:

First NameLast Name
Health History

For Whom the PEMF or Red Light/Near Infrared Light Therapy is for.
Why do you want to try PEMF or RL/NIL Therapy?*
Are you currently taking any medication?*

YesNo
If yes, for what, and which drug(s)
I have a pacemaker, defibrillator, cochlear implant, and/or an implanted medical device that cannot be removed.*

YesNo
I have a stent*

YesNo
I have and use removable hearing aids*

YesNo
I have and use an insulin pump*

YesNo
If yes, can it be removed?

YesNo
I am pregnant*

YesNoI might be/I'm trying
I have high blood pressure*

YesNo
If yes, I am taking medication for it

YesNo
I have low blood pressure*

YesNo
If yes, I am taking medication for it

YesNo
I have a history of light-headedness, fainting, or dizziness that has not been diagnosed by my healthcare provider*

YesNo
I have or have had cancer*

YesNo
If yes, what type
If you are in remission, for how long?
I am currently undergoing chemotherapy or radiation therapy*

YesNo
My chemotherapy and/or radiation therapy treatments are scheduled to end: (date)
I have had an organ transplant*

YesNo
I have had surgery resulting in the placement of metal implants*

YesNo
If yes, describe
I have a blood clot*

YesNo
I have had a head injury within 30 days*

YesNo
If yes, describe
Availability - Please let me know your preference for days/dates/time of day and I'll do my best to accommodate.
Legal

Please read the following carefully.
I understand that PEMF therapy is not a replacement for medical care and no diagnoses will be made.*

YesNo
I understand that if I have a pacemaker, am pregnant, had an organ transplant, or have any kind of implanted device with a battery that cannot to removed I do not qualify for PEMF therapy. (Light therapy *may be an alternative)*

YesNo
* Red light/near infrared light therapy may be a suitable alternative if you have medically implanted devices or have had an organ transplant. The practitioner can discuss this option with you if your criteria in this form apply.
I understand that fees owing must be paid within 30 days of services being performed or I will be subject to an interest of 10% added and compounded monthly.*

YesNo
(Optional) I consent to letting MearaPulse Therapies use my photos for marketing or training purposes.

YesNo
Legal Name (or name of parent/legal guardian)*

First NameLast Name
Signature

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Human Intake Form

Health History

Legal