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PEMF Initial Client Intake

First and Last Name

Email Address

Phone Number

How did you find us or who referred you?

What are your top 2 reasons for seeking PEMF

Check any of the following that apply to you

Check any of the following that apply to you

Do you have any metal implants (pins, plates, etc)

Do you have any metal implants (pins, plates, etc)
A
B

Write any serious medical conditions we should be aware of?

What brings you in today? Check all that apply.

What brings you in today? Check all that apply.

If other, please explain or write not applicable

Where in your body are you main areas of concern (check all that apply)

Where in your body are you main areas of concern (check all that apply)

Are you currently using any other therapies or approaches to support this concern? If so, please share:

Have you experienced High Intensity PEMF before?

Have you experienced High Intensity PEMF before?
A
B
C

Are you currently taking any medications we should be aware of? If so, please list:

I understand that PEMF is a supportive wellness modality and not a medical treatment.

I understand that PEMF is a supportive wellness modality and not a medical treatment.
A

I understand that individual responses to PEMF sessions may vary

I understand that individual responses to PEMF sessions may vary
A

I agree to communicate with the practitioner if I feel any discomfort during or after the session

I agree to communicate with the practitioner if I feel any discomfort during or after the session
A

I understand that each person may respond differently to a PEMF session. Many people experience benefits such as relaxation, increased energy, and a reduction in symptoms. However, I acknowledge that some individuals may have temporary detox responses, including mild fatigue, emotional release, temporary soreness, or detox-like sensations such as headache or thirst.

I understand that each person may respond differently to a PEMF session. Many people experience benefits such as relaxation, increased energy, and a reduction in symptoms. However, I acknowledge that some individuals may have temporary detox responses, including mild fatigue, emotional release, temporary soreness, or detox-like sensations such as headache or thirst.
A

I acknowledge that the PEMF session will take place in a home office in North Naramata

I acknowledge that the PEMF session will take place in a home office in North Naramata
A

I understand that typical sessions are 60 minutes in total, with the experience tailored to your individual needs.

I understand that typical sessions are 60 minutes in total, with the experience tailored to your individual needs.
A

I understand the session rate is $70 per 60-minute session (plus applicable 5% GST of $3.50).

A $35 deposit is required to book (via e-transfer or payment link), with the remaining balance due at the end of the session (cash, credit card, or e-transfer).

Deposits are refundable with a minimum of 24 hours’ notice.

I understand the session rate is $70 per 60-minute session (plus applicable 5% GST of $3.50). A $35 deposit is required to book (via e-transfer or payment link), with the remaining balance due at the end of the session (cash, credit card, or e-transfer). Deposits are refundable with a minimum of 24 hours’ notice.
A

I understand that after I submit this form, I will be contacted by Heidi if it's a fit and with calendar booking dates to book an initial appointment.

I understand that after I submit this form, I will be contacted by Heidi if it's a fit and with calendar booking dates to book an initial appointment.
A

I understand that on my first appointment, in person, I will be asked to sign a Release of Liability/Waiver of Claims form

I understand that on my first appointment, in person, I will be asked to sign a Release of Liability/Waiver of Claims form
A