BRILIN

PEMF First Session — Safety Screening & Informed Consent

Pulsed Electromagnetic Field (PEMF) session

Client Name

Date of Birth

Date

Phone

City

1. What to expect

PEMF equipment produces rapidly changing magnetic fields. Depending on setting and placement, you may feel pulsing/tapping, a mild shock-like sensation, or muscle twitching. Sensitivity varies. Your first session will be introduced gradually, and you may ask for the intensity to be reduced or the session to stop at any time.

2. Safety screening — complete before your first session

1.Do you have an implanted electronic device (for example, a pacemaker, implanted defibrillator, neurostimulator, implanted pump, or similar device)?

YESNO

2.Do you use or wear an electronic medical device that could be affected by a strong magnetic field?

YESNO

3.Do you have any implanted metal, surgical clips, joint replacement, dental implant, or other implant?

YESNO

4.Are you pregnant, think you may be pregnant, or trying to conceive?

YESNO

5.Have you previously had an unpleasant or unusually strong reaction to magnetic or electromagnetic therapies/devices?

YESNO

6.Is there any health condition, recent procedure, injury, or other concern Brilin should know about before PEMF?

YESNO

3. Before the session

Remove or move away items the practitioner identifies as potentially affected by the magnetic field, including metal jewellery, wallet/credit cards, electronic car keys, phones, watches, wearable electronics, or other sensitive electronics.

Main area to focus on

Pain/discomfort now (0-10)

Second area (if any)

Pain/discomfort now (0-10)

4. Client acknowledgement and consent

I have answered the safety questions accurately and will tell Brilin if anything changes.

I understand PEMF is not a medical diagnosis and is not a substitute for assessment or treatment by my doctor or other qualified healthcare professional.

I understand individual responses vary and no particular result or improvement is guaranteed.

I understand I may feel pulsing, tapping, muscle twitching, or discomfort and will tell the practitioner if the sensation is too strong or I feel unwell.

I can ask for the intensity to be reduced, pause the session, or stop the session at any time.

I have had the opportunity to ask questions and the information has been explained in a way I understand.

I voluntarily consent to receiving my first PEMF session at Brilin.

Signing this form records informed consent only. It does not remove or waive any rights you may have under New Zealand law.

Client Signature

Draw your signature here

Date

Please answer all safety screening questions to continue.