PEMF Nomination Form

Please do not nominate someone who does not meet the following:
1. Must live in Glendive or be able to come into the Glendive Office
2. Does not have electronic device implant such as cochlear implants, pacemaker, defibrilator
3. Insulin Pump Users can be considered IF they can remove their pump/transmitter for the duration of the session. PEMF has been shown to lower and stablize blood sugar. We can attempt to schedule around when a pump user is disconnected/changing the transmitter out.
4. NOT pregnant
5. No active bleeding (does assist with wound healing but don't want an actively bleeding wound). Menustrating women may wish to sit out of sessions during their cycle.
6. HIstory of seizures/blood clotting disorders please bring a doctor note.
7. If you have had an organ transplant

PEMF nomination form

* Indicates required field

Name of Person Being Nominated *

First

Last

Email of person being nominated *

Phone Number of Person being Nominated *

Name of Person Making the Nomination *

Phone Number of Person Making nomination *

I affirm I have told the person I am nominating about this nomination and they are in agreement to trying/accepting PEMF sessions if selected *

YES

Tell us a bit about the person you are nominating and why? What are their health concerns and medically diagnosed concerns? Why are they in need financially to receive consideration for free sessions? Please understand our availablity of free sessions may fluctutate month to month and that we will also be reviewing these requests for aid. Aid may vary from 1-3 introductory sessions free all the way up to 51 sessions free and/or any combination there of that our office admin will determine. There is NO guarantee that all sessions offered will be free but there is a MAX cap on free sessions per person offered of 51. At times sessions may be offered at reduced cost TBD by admin. *

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