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Do NOT use PEMF therapy if:

• You have an implanted electronic device including a pacemaker, defibrillator, cochlear hearing device,

spinal stimulator, etc.

• You are pregnant.

• You have been diagnosed with Grave’s disease or are actively bleeding.

Before beginning a PEMF session:

• Please remove all external metal (electronic or battery-operated devices, keys, wallets, metal belt

buckles, cards with magnetic strips, such as credit cards and hotel keys, jewelry, hearing aids, etc.)

• Inform your PEMF practitioner of the location of any metal implants you may have.

• Consult with a licensed health care provider if you are unsure whether pulsed magnetic cellular exercise

is right for you.

During your PEMF session:

• If you experience any natural reactions such as nausea, headache, fatigue or any uncomfortable

sensations, let your PEMF practitioner know right away.

I hereby request Pulsed Magnetic Cellular Exercise (aka PEMF therapy) with

RoMan Bear LLC. I understand that the Pulse Centers System produces magnetic field energy, which passes

freely through tissue for the purpose of cellular exercise to promote and support a sense of well-being. I

understand that the Pulse Centers System is not intended for the diagnosis, treatment or cure of any medical

condition and that the Pulse Centers System is not considered a medical device. Instead, PEMF devices

optimize the body’s natural self-healing and self-regulating function.

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Beyond what is stated above, I understand that other risks associated with a pulsed magnetic exercise session

are unforeseeable and that RoMan Bear LLC and its employees cannot accept any liability for loss or damages

incurred as the result of the PEMF therapy (Pulse Centers System) session. I reserve the right to use the

knowledge I have gained in the care of my own body in any legal manner I may choose. I have read this form

and voluntarily agree to the PEMF session on my person assuming all liability for any and all results and

consequences.

I have carefully read, fully understand, and agree to comply with the above safety instructions. This agreement is

in effect for all future PEMF therapy sessions/treatments at RoMan Bear LLC and will not expire unless

requested by either party.

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If you have booked your appointment or just waiting on confirmation please complete the new client liability and media release form below before the time of your first appointment with RoMan Bear.