Name *

Email *

Phone *

Mailing Address *

Emergency Contact Name *

Emergency Contact Phone *

Referred by:

Are you currently pregnant? *
YesNo

Are you 16 years of age or older? *
YesNo

Are you known to be photosensitive (i.e. Photoconvulsive Response, Epilepsy)? *
YesNo

Do you have a pacemaker? *
YesNo

Do you have an insulin pump? *
YesNo

Do you have any passive metallic implants such as plates or screws? *
YesNo

Please list your current health concerns in order of importance:

List any medical tests completed in the last 12 months related to your current concerns:

Please list any current medications, dosages, and frequency:

Please list any current supplements, dosages, and frequency:

Please rate your average stress levels on a scale of 1 to 10 during the average week (1 = no stress) *
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Please rate your average energy level on a scale of 1 to 10 (1 = no energy) *
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Have you had any of the following:
Chicken PoxCovid 19Covid 19 Vaccination(s)Diabetes Type IDiabetes Type IIGoutMold ExposureMonoShinglesSTDsThyroid ProblemsTick Borne IllnessYeast Infections/CandidaOther
Please Elaborate

Please provide any additional information you would like to share here:

I acknowledge and accept the risks inherent in the use of the BioCharger. I voluntarily assume the risk of injury, accident, or death, which may arise from the use of the BioCharger. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while on the premises, during the use of the BioCharger and from any advice provided by an employee, independent contractor, or any representative of Revive Health, LLC. I agree that this Application and Waiver is in effect for all BioCharger sessions and will not expire unless requested by either party.

Revive Health, LLC and its representatives, including but not limited to BioCharger, does not provide medical advice, diagnoses, or treatment. BioCharger may or may not be appropriate for you. The BioCharger is only used as an adjunctive therapy and is not intended to replace any medical treatment from my doctor. Do not attempt to self-treat any disease with the BioCharger. Please consult your health care provider for medical advice. I further acknowledge that Jill Durand from Revive Health, LLC is not a doctor and any advice on dietary changes or restrictions, including taking supplements, is to be done at my own risk.

Individuals who do not cancel their appointment within 24 hours will be charged a $20 cancellation fee.

Full Name *

Date of Signature *

Signature required *