Release for PEMF Session

Release for PEMF Session

Aurora Pulse Therapy
DATE

MeseGiornoAnno
2 digit month, 2 digit day, 4 digit yearData
NAME
GENDER
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
Format: (000) 000-0000.
EMAIL
esempio@esempio.com
I hereby state that I am at least 18 years of age and have read, understand and agree to this Release Statement, that it is an informed release and that I intend to be legally bound by it.
- I am not pregnant
- I have no pacemaker or other battery operated implanted stimulator
- I do not suffer from active bleeding
- I have not had an organ transplant
- I do not have any chains on me (jewelry is OK)
- I do not have any car key, credit card, cell phone or watch on me
- I agree to be fully responsible for any damages if I forget this
- I know that I am using a magnetic pulse generator that is not approved by the FDA to treat or cure any disease or condition
- I understand that this is an experimental device
No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind.
I release, Aurora Pulse Therapy, from all general, medical and any other liability or claims of any kind; and, I indemnify and hold harmless the Pulsed Electro-Magnetic Field generator, the manufacturer, distributor, dealer and any of their employees or agents from any claim arising from or related to my use of the magnetic pulse generator.
PRINTED NAME
Date

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