Dog | SURGE Equine

Canine PEMF Therapy Session Release Form

Owners Full Name

Phone

Street Address

City

State

Zip code

Dog's Name

Dog's Age

Name of Veternarian

Sex

Male

Female

Is this dog currently on or recently been on any medication?

Yes

Start Date of Treatmet

End Date of Treatmet

Please specify anything we should know about, including any current medication

MagnaWave creates more cell permeability, thus medications and liniments may be absorbed more than intended.

I declare that the info I’ve provided is accurate & complete. I hereby state that I am at least 18 years of age and have read, understand and agree to this Release Statement, that it is an informed release and that I intend to be legally bound by it. I understand the information below is intended for my safety and that of my horse(s). No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind. I release from all general, medical and any other liability or claims of any kind; and, I indemnify and hold harmless the MagnaWave magnetic pulse generator, the manufacturer, distributor, dealer and any of their employees or agents from any claim arising from or related to my use of the magnetic pulse generator

Enter full name as a forme of signature

Thanks, you are good to go!