Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Do you have any of the following medical conditions: *

Place a checkmark next to all conditions you do have

Metal medical implants

Deep vein thrombosis, or known thrombi

Open wounds

Acute inflammations, or tumors

Recently had surgery

Cartoid atherosclerosis

Eczema

Diseased Veins

Inflammatory skin disorders

Other inflammatory processes generally associated with fever

Cardiac pacemaker, artificial heart valves, defibrillator, or cardiac arrhythmias

Shunt/Stent

Deep Brain Stimulation device (DBS)

Whiplash in the last 3 days

None of the above conditions

By selecting this box, you confirm that all information given is accurate and correct at the time of submission. Any changes in medical status that may affect our sessions must be reported to me at your earliest convenience. *

I acknowledge that all information provided in this document is accurate