PEMF Intake and Waivers

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you received Pulsed Electromagnetic Field Therapy before? *

Yes

No

Unsure

Are you pregnant? *

Yes

No

Are you currently under the care of a medical professional (doctor/physiotherapist/allied health professional/nutritionist etc)

Yes

No

Treating Doctor/Physician/Specialist Name

First Name

Last Name

Treating Doctor/Physician/Specialist Phone

(###)

###

####

Do you give permission for me to contact your Doctor/Physician/Specialist if more information is required?

Yes

No

On a per case basis

Are you on anticoagulants? *

Yes

No

Are you on Bisphophonates? (Clearance from primary care providers is required prior to Pulsing) *

Yes

No

Are you currently taking Immunosuppressant drugs? *

Yes

No

Have you receiving any injections into the joint(s)? *

Yes

No

Are you currently taking any pain medications or nerve blockers? *

Yes

No

Are you currently taking Sedatives? *

Some studies show that PEMF may reduce the duration of medical sedation

Yes

No

Are you currently administering any topical medication? *

Yes

No

Do you have breast implants?

Yes

No

Do you have any Electrical Implants? *

PEMF may interfere with battery-operated electrical implants, presenting a risk of implanted device failure

Yes

No

Do you have an IUD?

Yes

No

Do you have Magnetic Implants? *

An electromagnetic field may affect magnetic implants, causing discomfort or pain as the implant may more or twist inside the body

Yes

No

Do you have Metal Implants? *

Most metal implant materials are generally safe to Pulse

Yes

No