Human Intake Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Email Address
*
example@example.com
How would you like to be contacted?
*
Text
Phone Call
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a parent/guardian filling out this form on behalf of a minor for whom the PEMF or red light/near infrared session is intended.
No
Yes
If yes, the minor's name is:
First Name
Last Name
Health History
For Whom the PEMF or Red Light/Near Infrared Light Therapy is for.
Check any symptoms or concerns that you' re currently experiencing:
Respiratory/COPD
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Anxiety
Depression
Gastrointestinal
Weight gain
Weight loss
Muscle Pain
Back Pain
Trouble Sleeping
Post-Concussion Syndrome
Headaches
Other
Why do you want to try PEMF or RL/NIL Therapy?
*
Are you currently taking any medication?
*
Yes
No
If yes, for what, and which drug(s)
I have a pacemaker
*
Yes
No
I have a defibrillator
*
Yes
No
I have a stent
*
Yes
No
I have and use removable hearing aids
*
Yes
No
I have a cochlear implant
*
Yes
No
I have and use an insulin pump
*
Yes
No
If yes, can it be removed?
Yes
No
I am pregnant
*
Yes
No
I might be/I'm trying
I have high blood pressure
*
Yes
No
If yes, I am taking medication for it
Yes
No
I have low blood pressure
*
Yes
No
If yes, I am taking medication for it
Yes
No
I have a history of light-headedness, fainting, or dizziness that has not been diagnosed by my healthcare provider
*
Yes
No
I have or have had cancer
*
Yes
No
If yes, what type
If you are in remission, for how long?
I am currently undergoing chemotherapy or radiation therapy
*
Yes
No
My chemotherapy and/or radiation therapy treatments are scheduled to end: (date)
I have had an organ transplant
*
Yes
No
I have had surgery resulting in the placement of metal implants
*
Yes
No
If yes, describe
I have a blood clot
*
Yes
No
I have had a head injury within 30 days
*
Yes
No
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.
*
Yes
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.
*
Yes
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.
*
Yes
(Optional) I consent to letting MearaPulse Therapies use my photos for marketing or training purposes.
*
Yes
No
Legal Name (or name of parent/legal guardian)
*
First Name
Last Name
Signature
Submit
Submit
Clear All Answers
Should be Empty: