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Clarion Vitality - PEMF In-take Form

Please fill out the following form.

Personal Information

Date of birth
Month
Day
Year

Emergency Contact Info

Health & Wellness Background

Are you currently under the care of a physician or specialist?
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Do you have any implanted medical devices? (Check all that apply)
Are you currently pregnant or breastfeeding?
Do you have any of the following conditions?

Lifestyle and Stress

How would you rate your current stress levels?
How would you describe your current activity level?
What are your primary wellness goals? (Check all that apply)

PEMF Experience

Have you received PEMF before?

Consent & Agreement

I understand that PEMF therapy is a non‑medical wellness modality and is not a substitute for medical diagnosis or treatment. I agree to inform my practitioner of any changes in my health status. I acknowledge that results vary and no specific outcomes are guaranteed.

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