Customer Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number *

(###)

###

####

Do you have a history of Cancer and undergone radiotherapy or chemotherapy in the past 5 years? *

No

Yes

Are you taking or have taken steroids/cortisone in the past 12 months? *

No

Yes

Are you allergic to any materials or products used? *

No

Yes

Do you have a pacemaker or suffered heart conditions in the past? *

No

Yes

Are you suffering from any form of liver or kidney disease? *

No

Yes

Are you suffering from or had fibrosis, Hepatitis (all forms)? *

No

Yes

Are you recovering from an operation within the last 6 weeks? *

No

Yes

Are you diagnosed with any long-term medical conditions? *

No

Yes

Are you suffering from osteoarthritis? *

No

Yes

Are you pregnant or breastfeeding? *

No

Yes

Have you had acne treatment (Ro-accutane) within the past 6 months? *

No

Yes

Are you Diabetic? *

No

Yes

Do you have kidney disease? *

No

Yes

Do you suffer from thyroid disorders? *

No

Yes

Do you suffer from Epilepsy? *

No

Yes

Are you on any blood-thinning medication? *

No

Yes

Do you have any active blood clots? *

No

Yes

Do you suffer from any skin conditions or diseases? (Eczema, Psoriasis, etc.) *

No

Yes

Do you suffer from any other allergies? *

No

Yes

Do you suffer with blackouts, fainting, or dizziness? *

No

Yes

Do you have any silica implants? *

No

Yes

Do you have high blood pressure? *

No

Yes

Do you have any metal plates or pins in your body? *

No

Yes

Do you have any contraceptive coil, specifically copper – non-hormonal? *

No

Yes

CONSENT *

I have read and fully understand the terms & cancellation policy

Yes