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Form 1 of 3

Health Intake & Release Form

Required for any human session. Please review each release section carefully before signing off.

First Name
Last Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code

Format: (000) 000-0000

Release Statement

I am at least 18 years of age and have read, understand, and agree to this Release Statement, that it is an informed release, and that I intend to be legally bound to it.

  • I am not pregnant.
  • I do not have a pacemaker, cochlear implant, or other battery-operated implanted stimulator.
  • I have not had an organ transplant.
  • I am not currently undergoing any cancer-related treatments.
  • I have removed any car keys, credit cards, cell phones, or watches.
  • I agree to be fully responsible for any damages if I forget to do this.
  • I agree that no one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind.

I release from all general, medical, and any other liability or claims of any kind, and I indemnify and hold harmless the Aura and/or MagnaWave magnetic pulse generator, the manufacturer, distributor, dealer, and any of their employees or agents from any claim arising from or related to my use of a magnetic pulse generator.

I grant media release permission for my likeness or image to be used in a variety of media, including photographs, videos, and audio recordings. I waive any right to compensation for the use of my image or likeness. I also waive my right to inspect or approve how my image or likeness is used.