Healing Beyond the Physical

Name *

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Last Name

Date of Birth

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Address

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Medical History

Please indicate if you have any of the following conditions (Check all that apply): Contraindications (Should Avoid PEMF Therapy Completely):

Pregnant or possibly pregnant

Pacemaker or implanted electronic devices (e.g., insulin pump, defibrillator)

Epilepsy or seizure disorders

Active bleeding or hemorrhagic conditions

Organ transplant recipient

Relative Contraindications (Proceed with Caution):

Severe hypotension (low blood pressure)

Uncontrolled hypertension (high blood pressure)

Recent surgeries (within last 8 weeks)

Acute injury (within last 4 weeks)

Active infection

Cancer (current diagnosis or treatment within last 2 years)

Hyperthyroidism

Neurological or psychiatric conditions (e.g., severe anxiety, bipolar disorder, schizophrenia)

High fever or acute illness

Addiitonal Information

Are you currently taking any medications? (List):

Are you receiving any other therapies or treatments? (Describe):

Consent and Acknowledgment I confirm that the above information is accurate and complete. I understand that PEMF therapy is generally safe, but certain medical conditions require caution or may contraindicate the treatment entirely. I agree to disclose any changes in my medical condition and medications during my course of PEMF therapy. *

Yes

No

Digital Consent

By typing your full name below, you acknowledge that this serves as your legally binding digital signature and confirm that you have read, understood, and agreed to the terms outlined above.

First Name

Last Name

Date

MM

DD

YYYY