Acknowledgement Form

By completing this form, you acknowledge that Frequency Specific Microcurrent (FSM), Photobiomodulation (PBM) and Ozone Therapy are intended for your general health and wellness only. Licensed Health Practitioners may use these devices for prevention or treatment of disorders/diseases. At The Fountain Place, these services are used to support general health and wellness and are NOT used to prevent, treat or diagnose in any way. They are not a substitute for medical advice or treatment for specific medical conditions or disorders. Services at The Fountain Place are overseen by a registered nurse whose scope of practice is education, teaching, supporting/coaching health & wellness. You should seek prompt medical care for any specific health issue. 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 preautions/contradictions. I acknowledge that PBM is contraindicated over skin cancer (current or history of), the neck region in hyperthyroidism, the brain in epilepsy, the retina, and a pregnant abdomen. *

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 understand that no guarantees are being made about the results of FSM therapy, and that outcomes vary from person to person. I take full responsibility for my own health and wellness and choose to have PBM/FSM therapy as a wellness service. *

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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