PULSED MAGNETIC THERAPY Consent Form
WARNING
Do not use this machine without consent or supervision
Contraindications and warnings:
 ABSOLUTE CONTRAINDICATIONS: Implanted electrical devices including but not limited
to cardiac pacemakers, cardiac defibrillators, deep brain stimulators, gastric stimulators,
insulin pumps, foot drop implants, cochlear implants, and other similar devices.
 Pregnancy
 Organ Transplant
 Hyperthyroidism or other over-active glands.
 Patients currently receiving chemotherapy treatments.
 Do not be treated with PEMF within 1 day before or after surgery.
CAUTION
 Implanted metals-such as joint replacements, dental implants or other dental metal
devices, mechanical heart valves, metal stents, or metal staples in blood vessels should
PEMF devices with caution or medical guidance.
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Do not use the PEMF device near computers, laptops, cell phones, credit cards or security
access cards, car keys with embedded chips or jewelry with metal chains-this could cause
damage to the items.
Possible side effects:
 In patients with low blood pressure dizziness could occur for a few minutes after
treatment, use caution when standing.
 Patients currently receiving pain, anxiety, depression or any other medication should
exercise caution as the medication may become intensified; the patient could become
groggy, do not drive or operate machinery if this occurs.
 Drink plenty of water for the next 24 hours after using the PEMF device.
By signing this form I acknowledge I have read and understand the information provided on this
form, agree with it and take personal responsibility to proceed with the PEMF treatment. I
understand my signature below Indicates:
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The procedure has been adequately explained to you by your physician, practitioner or
nurse.
You have received all the information and explanation you desire concerning the
procedure.
You authorize and consent to the performance of the procedure(s).
You release the attending physician(s), nurse(s), medical assistant(s)
Holistic Medical Services and its staff including temporary personnel, agency personnel,
students, volunteers, residents, contractors and subcontractors from any side effects or
any of the risks involved with this treatment.
Patient Name (Printed): ____________________________________________
Patient Signature: ________________________________________________
Witness: ________________________________________________________
If signed by representative, indicate relationship: ______________________
Date: ___________________________________________________________