PEMF Therapy Intake Form

First Name

Last Name

Birthday

Month

Day

Year

Phone

Do NOT use PEMF if you have an implanted electronic device including but not limited to a pacemaker, defibrillator, cochlear hearing device, spinal stimulator, glucose monitor, or insulin pump, if you are pregnant or believe you may be pregnant, if you are actively bleeding or hemorrhaging, if you are the recipient of an organ transplant, or if you have injuries or concerns of injuries that have not been evaluated by a licensed health care provider.

Initals:

What medications are you on and what are they for? Please include pharmaceuticals, over the counter medications, and supplements.

Brief history of surgeries, illnesses, or medical issues:

Daily activities (work, exercise, wellness regimen):

Please look in your email for our reply (also check your spam folder). It is easier to get you set up for an evaluation phone call to answer any questions or concerns. Also, we ask for at least 1-2 business days for our reply. We appreciate your patience!