PEMF Therapy Registration Agreement

PEMF Therapy Agreement

Please note that all fields followed by an asterisk must be filled in.

If Applicable, please provide date of last treatment Month/Day/Year

If you have had a previous treatment please provide feedback since your last session

Where would you llike your PEMF Therapy Session*

	I will attend your clinic, in Wellesley Ontaio N0B 2T0
	Yes I would like a house call. I will provide address with details, below
	Please contact me for an appointment, the next time your coming to my City

For House calls, provide full address, preferred dates and times, and details on location, or directions

CUSTOMER, First and Last Name*

E-Mail Address*

Street Address*

Country*

Cell Phone 1-*

Alternative Phone 1-

DATE OF BIRTH (MO/DY/YR)*

Best time/hours to call*

	Early AM 5:30 am - 8:30 am
	AM 8:30 am -11:30 am
	Noon 11: 30 am-1:30 pm
	PM 1:30 pm - 4:30 pm
	Evening 5:30 pm - 8:30 pm
	Late PM 8:30 pm - 11:30 pm

Best days to call*

	Any day
	Saturday
	Sunday
	Monday
	Tuesday
	Wednesday
	Thursday
	Friday
	Mondays - Fridays

My present health issues or concerns are:*

I am a *

	Smoker
	Non-Smoker

indicate pain or discomfort in the following areas*

	Right Ankle
	Left Ankle
	Right Knee
	Left knee
	Right Ankle
	Left Ankle
	Right wrist
	Left wrist
	Right shoulder
	Left shoulder
	Abdominal upper
	Abdominal lower
	Lower back
	upper back
	Forehead
	Back of head
	Right side ear or area
	left side ear or area
	Throat
	Neck
	Left Eye
	Right Eye
	Nose

Rank your level of sensitivity*

	Touch of a finger I wince
	Sight of a needle I faint
	Touch of a needle I squeel
	Sight of blood I get upset
	Sight of blood I faint
	scrape of a knee I cry
	Scrape of a knee I curse
	I have a low tolerance to pain
	I have a mild tolerance to pain
	I have a high tolerance to pain
	I can do without an anesthetic for dental work
	No Gain No Pain
	Sensitive to smell
	Sensitive to temperature

What is your present level of fitness*

	Excellent
	Moderate
	Motivated to improve
	Wish to improve
	Poor

Rank the following between 1 - 10; 1 Extreme. never been worse, great amount of discomfort or pain, 10 You have no issue and are very satisfiedis

Pain: 1 Great shape 10 Worse pain

Inflammation 1-10

Immunity 1-10

Stress 1-10

Headaches 1-10

Ability to Focus 1-10

Attention to detail 1-10

Joint pain 1-10

Arthritis 1-10

Osteoprosis 1-10

Hyperactivity 1-10

Ability to focus/attentiveness 1-10

Fatigue 1-10

Physical strength 1-10

Endurance 1-10

Sleep 1-10

Memory/recall term 1-10

Other: 1 Great shape 10 Worse pain

I agree to the following polices and practices for PEMF /AVE treatments(check mark each)

1 No large meals prior to your treatment, if you’re going to eat a full meal, makes sure it’s at least 3 hours prior

2 No metal objects, attachments or jewelry of any kind are allowed; metals can cause negative side effects, and in some extreme cases, Death. It may also cause equipment to malfunction.

3 We discourage persons with any surgically attached technology or metals within their body, from participating in therapy, as you risk shutting down or irritate the surgical area within. If you fall within this category, Talk to your doctor about the possibilities about PEMF treatment. We also require a note from your doctor, that allows you to participate in treatments.

4 No mothers going through Pregnancy.

5 No person diagnosed with Epilepsy, may participate in therapy

6 No medication that can affect the state of your blood, such as thinners or coagulators. PEMF triggers the process of NOx which activate the arteries to expand, allowing blood to flow easier, which in turn lowers the blood pressure . PEMF combined with medication may have a doubling effect or may neutralize the medication. If you fall within this category, Talk to your doctor about the possibilities of avoiding meds on day of scheduled treatment. We also require a note from your doctor, that allows you to participate in treatments.

7 I will disclose all health issues or concerns prior to treatment, as it will have a bearing on the level of treatment, you will undergo.

8 Update us on any changes in medication, and your present status on use in conjunction with your next treatment.

9 Before any session, if you have serious health issues, preconditions, been monitored, prescribed or treated by a health professional, you must provide proof of consent by your doctor, to go ahead with PEMF Therapy.

10 Keep records and share your progress from how you rated yourself before and through your treatment,

11 If you easily perspire, bring a towel and face cloth, to use during your sessions.

12 Drink water before you arrive as it will assist in the detoxification process. Allowing your body to excrete toxins from your body.

13 Wear loose clothing that makes you feel relax, with no metal attachments and is appropriate to wear in a public facility. You may bring a change of close, as well.

14 On days of PEMF Therapy, Take in binders with your daily fluid intake, to reduce the side effects of Detox.

I acknowledge and agree to the following terms and conditions*

I acknowledge that the PEMF Therapy Awareness Program, is a voluntary Program and that I am not obligated to participate in any activities and that I may be guided and/or educated on the topic of PEMF Therapy. I will administer my own treatments if I choose to participate and will not hold Born to Ride bicycle nor their staff or representatives liable or responsible for the results and/or side effects if any. I voluntarily choose to participate. All participation is at my own risk. All equipment may be monitored at times, on their use. I acknowledge that I am in sound mind and able to control or administer the use and application of any treatments I choose to participate in. If I am the legal guardian, have power of attorney over the participant, or been given verbal or written consent by the person willingly participating in the program, I KNOWINGLY REPRESENT THE PARTICIPANT AND ACCEPT ALL RESPONSIBILITIES AS IF I AM THE PARTICIPANT.

I acknowledge*

Born To Ride Bicycle makes no claims to the effective use of Pulsed Electro-Magnetic Therapy and that we rely upon Medical Research, feedback from clients, staff, suppliers and eye witness experiences.

Are you taking any blood thinner medication

	YES
	NO

Do you use a electronic Heart Device

	YES
	NO

For All your presecribed medication, surgical devices, and metal attachments, please provide the Description and application of use

OFFICE USE ONLY

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PEMF Therapy Registration Agreement

PEMF Therapy Agreement

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