Application for PEMF Community Giveback Relief Program

Angela A. Dockter, LLC.

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Due to a decline in interest in this service in the local area, this program has been temporarily suspended as there is not enough incoming community financial support to donate sessions free of charge to those who need it most. If you are interested in PEMF sessions and struggle to make the financial commitment please reach out to use using this form anyway and please note that in comments. Please make an offer of a donation you CAN afford to make for each session (based on an hour) and we will review it for consideration and get back to you. We sincerely hope those in the community who can afford it will one day again embrace this service in full so that we can offer to giveback to those in the community who need it most.

Application for PEMF Community Giveback Relief Program

* Indicates required field

Name *

First

Last

Email *

Best Contact Number *

Describe your Income Situation *

Number of People living in the household under the age of 18 *

Does anyone else contribute to the income in the household in any manner? Just yes/ no. *

Household Income *

Less than 25,000 per year 25,000-50,000 per year 50,000-75,000 per year 75,000 or above

Rent or Own your Home? *

Amount of Rent or House Payment *

Amount of Medical related debt *

Breifly list any medical diagnosis you have *

What are you seeking PEMF for? *

I affirm I have read the disqualifying medical conditions for which I cannot use PEMF and do not have any of them. *

Yes No

I understand that if I am selected for this giveback program I may be dropped immediately and without notice if I fail to cancel an appointment with less than 24 hours notice, or if I miss a session, or no-show, or if I am late to an appointment. If I am late, minutes will be deducted off my scheduled time and I will not be able to recoup them. I will do my part and be respectful and responsbile and keep any scheduled appointements. *

Yes No

I affirm I am physically able to come to the designated office location in Glendive. *

Yes No

I understand program offers will vary per applicant and that not all sessions are guaranteed to be free but may be a combination of free or reduced. I furthermore each client will be individually assessed based on a number of individual factors as well as program availablity determined by office administration. I furthermore agree to no discuss terms of my arrangements with anyone else in the community and only advertised programs and prices are public knowledge. *

Yes I agree No I declne

Please share with us any extenuating circumstances you think we should consider in offering financial relief to you for PEMF sessions. *

Please finish up by reviewing the Contraindications for PEMF using the link below AND be sure to electronically sign the consent using the link provided. Our office staff will be in touch to follow up with you within 7-10 business days if you are selected as a participant.

Submit

Who cannot use PEMF: PEMF FAQ
Electronic Consent: PEMF Consent

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