PBM/FSM Acknowledgement Form

By completing this form, you acknowledge that Photobiomodulation (PBM) and Frequency Specific Microcurrent (FSM) is intended for your general health and wellness only. It is not a substitute for medical advice or treatment for specific medical conditions or disorders. The Fountain Place does not diagnose or treat disease. You should seek prompt medical care for any specific health issues. Treatment modalities around your specific health issues are between you and your physician.

Yes, I understand.

1. I have been given information and all my questions have been answered about Photobiomodulation and the LZR Ultrabright device: how it works, the benefits, any side effects, and any contradictions. *

Yes

N/A

2. I have been given information and all my questions have been answered about Frequency Specific Microcurrent (FSM): How it works, the benefits, any side effects, and any precautions/contraindications. *

Yes

N/A

3. I acknowledge that FSM is contraindicated in pregnancy. If I have any of the following conditions, I understand and take responsibility to adhere to the appropriate precautions when using FSM: Having a demand type pacemaker, an injury that is less than 6 weeks old, fibromyalgia due to cervical spine trauma, spinal cord compression or stenosis, an infection or encapsulated infection anywhere. *

Yes

N/A

4. I take full responsibility for my own health and wellness and choose to administer PBM/FSM therapy on myself. *

Yes

5. I have read and agreed to the Terms and Conditions set forth above (Acknowledgment and Informed Consent and Membership Agreement) and I understand that by typing my name below, this is accepted as an electronic signature of agreement. *

Yes

Name *

First Name

Last Name

Date *

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