Mountain Pulse Therapy - Customer Consent Form

* understands that Pulsed Electromagnetic therapy (PEMF) is not a substitute for veterinary or medical care of veterinary or medical medicine. The patient understands that PEMF operators do not cure, treat, or diagnose illness, injury, or medical conditions. Contact your doctor or veterinarian immediately if you/your animal appears ill or injured.

Animal

Animal/horse owners understand that PEMF sessions, especially for illness, injury, disorder, or condition requiring medical treatment, are not intended to replace veterinary care. It may be used with such care to facilitate healing and maintain overall wellness.

The contradictions in the use of PEMF include:

Pregnant animals/mares
Areas of active bleeding
Instances of colic that have not been first evaluated by a licensed veterinarian and deemed appropriate to succeed
If you believe your horse/animal is experiencing a medical emergency, please consult your veterinarian before the PEMF session.

Human

The contradictions for humans or around animals while PEMF is in use:

Do not participate in a PEMF session if you have an implanted electrical device
Do not assist with or receive PEMF if you are currently pregnant, actively bleeding/hemorrhaging
Remove all magnetic or electrical devices from your person, including credit cards, hotel keys, cellular devices, and jewelry in areas of application.

Possible side effects of PEMF include nausea, headaches, muscle soreness, and increased menstrual flow.

The information presented by Pulse Centers and Pulse Equine representatives is offered to educate animal/horse owners and human PEMF users. The horse/animal/owner/participant fully consents to treatment by Mountain Pulse Therapy for PEMF sessions on his/her animal/horse today and on all agreed-upon dates between the parties.

The horse/animal owner or person receiving or in proximity to PEMF hereby releases Mountain Pulse Therapy from any loss, damage, liability, or injury arising from or resulting from participation in PEMF sessions, including any negligent acts or omissions.

The horse/animal owner or person receiving or in proximity to PEMF shall indemnify, hold harmless, and defend Mountain Pulse Therapy from any resulting loss, damage, liability, or injury caused directly or indirectly by his/her acts or omissions.

The horse/animal owner or person receiving or in proximity to PEMF acknowledges that activities with and around horses/animals involve inherent risks of physical injury to participants, horses, and other animals or humans and hereby acknowledges and accepts any risk associated therewith.

I grant Mountain Pulse Therapy, its representatives, and employees the right to photograph me and my property (i.e., horse/animal) during a PEMF session. I authorize Mountain Pulse Therapy, its assignees, and transfers, to copyright, use, publish, print, and/or use electronically. I agree Mountain Pulse Therapy may use photos/videos of me or my property/animals with or without my name and for any lawful purposes, including but not limited to publicity, illustration, marketing, and web content.

Name of individual or owner/guardian of the animal/horse*

First NameLast Name

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Veterinary Name (if applicable)

First NameLast Name

Veterinary Phone number

How would you like to pay?

VenmoInvoice from Square

Venmo Account

By signing this form, I hereby state that I have read this INFORMED CONSENT FORM/ RELEASE OF LIABILITY in complete detail and understand the risks and consequences.

Date

Signature