Name *

First Name

Last Name

Phone *

(###)

###

####

Please check the box to acknowledge. *

I understand that the bio electric treatment given to me, is for the purpose of stress reduction, pain reduction, relief from muscle tension, and/or increasing circulation.

Please check the box to acknowledge. *

I understand that the therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of the therapy.

Please check the box to acknowledge. *

I understand that this therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.

Please check any conditions you have.

Thrombosis

Phlebitis

Hypertension or blood pressure higher than 160/110 mmHg

High Anxiety meds

Lung/Kidney Failure

Acute infectious Diseases

Osteoporosis

Angina

Epilepsy

Pinched Nerves

Fracture

Metal/Silicone implants

Pregnancy

Menstruation

Hemorrhagic disease

Psoriasis/Eczema

Pacemakers

Cancer

Heart problems/failure

Nervous/Psychotic Conditions

Diabetes

Malignancy

Other Serious Condition

By checking this box, I waive and release my bio electric therapist from any and all liability relating to this session. *