Informed Consent - PEMF IT Cedar Park TX

Informed Consent Form

Informed Consent for Demonstration, SESSIONS and / or Program Purchases:

I hereby request a Pulsed Magnetic Cellular Exercise session/s. I understand that the Pulse PEMF System creates a fully adjustable pulsed magnetic field. I understand that the information shared by the demonstrator are his/her personal opinions and are intended for educational purposes only.

Product Disclaimer

The Pulse PEMF System produces magnetic field energy, which passes freely through tissue for the purpose of cellular exercise to promote and support a sense of well-being. The FDA has not evaluated the Pulse PEMF System. It is not intended for the diagnosis, treatment or cure of any medical condition. The Pulse PEMF System is not a medical device, and we cannot make any claims that we can affect medical conditions.

We understand this general statement regarding pulsing magnetic fields to be accurate:

“PEMF (pulsed electromagnetic field) devices do not treat a specific condition. Instead they optimize the body’s natural self-healing and self-regulating function.” – Dr. Magda Havas Associate Professor of Environmental & Resource Studies at Trent University

DO NOT USE IF:

You have an implanted electronic device including: pacemaker, defibrillator, cochlear hearing device, spinal stimulator, nerve stimulator etc.
You are an organ donor recipient, or on anti rejection medication.
You are pregnant.
You are actively bleeding, hemorrhaging, or during heavy menstruation.

Good Health

I represent and warrant that I am physically sound and suffering from no condition, impairment, disease, infirmity, or other illness
that would prevent the safe participation in a Pulsed Magnetic Cellular Exercise session.
My participation in the Session is completely voluntary. I assume full and sole responsibility for my health and safety and for all
risks, injuries, or unforeseen side effects that I may incur as a result of participating in the Session.

Before beginning a PEMF Exercise Session we recommend the following:

Please remove all external metal, e.g.: Electronic or battery operated devices, keys, wallets, metal belt buckles, cards with magnetic strips such as credit cards and hotel keys, jewelry, hearing aids, etc.
Regarding metal implants, they can be a sensitive area. Therefore, we recommend pulsing at a level where the user feels comfortable.
If you are unsure whether pulsed magnetic cellular exercise is right for you, consult with your licensed health care provider (s).

During a PEMF Exercise Session

If you experience natural reactions that include but are not limited to nausea, headache, fatigue or any uncomfortable sensations we recommend you suspend the session and consult your doctor.

Release of Liability

I assume and hereby release, discharge and covenant not to sue or make any claim against PEMF IT, LLC, the manufacturer of Pulse PEMF System and their officers, agents, employees, and agents and affiliates (the “Released Parties”) with respect to any and all judgments, losses, damages, causes of action, suits and liabilities of ever kind and character, including but not limited to claims of physical or psychological illness or injury, bodily harm, medical expenses, death, damage to property, and loss of personal property, regardless of whether such claims arise in whole or in part from the acts, omissions, or negligence of the Released Parties. I agree to indemnify the Released Parties for any claim, liability or causes of action by third parties, including other users, for incidences related to my use of the Pulse PEMF System.

This agreement shall be governed by the laws of the State of Texas. To the extent any provision of this Agreement is held unlawful, void, or for any reason unenforceable, such provision shall be deemed severable from this document and shall not affect the validity or enforceability of the remaining provisions.

I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT IN ITS ENTIRETY, AND I AM SIGNING IT FREELY AND VOLUNTARILY. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.

If under 18, parents must sign individually and as parent/guardian.

Full Name *

Email *

Phone *

Informed Consent Agreement *

Yes, I understand the information and agree with the terms contained within this document. Yes, I agree that by typing my Full Name above and clicking on the “Submit” button below I am electronically signing this document.

Parent Informed Consent Agreement (If needed)

I hereby certify that I am a parent or guardian with legal responsibility for the individual identified above. I consent that the individual identified above may participate in the Class, and I agree to be bound by all the terms and conditions in this Agreement on behalf of the individual identified above, myself, heirs, legal representative, and other parents or guardians. Yes, I understand the information and agree with the terms contained within this document. Yes, I agree that by typing my Full Name and clicking on the “Submit” button below I am electronically signing this document.

Parent Full Name (If needed)

Comment

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