Patient Evaluation Intake Form

Date (mm/dd/yyyy)

Full Name *

First

Last

Date of Birth (mm/dd/yyyy) *

CONTRAINDICATIONS FOR ARP:

NOTE: FDA requires that you answer "Yes" or "No" to EACH of the following six questions. If you have a contraindication, please notate it, scroll down to the bottom of this form, and click submit. If you do not have a contraindication, please notate and continue filling out the form; hit submit once the form is completed. Unfortunately, if you have a contraindication listed below, FDA will not allow ARPwave to ship or utilize any ARPwave devices with you.

Are You Pregnant? *

Do You Have a Pacemaker? *

History of Blood Clots *

Specific Area of Pain:

Rate the Intensity of Your Pain:

Describe Your Complaints/Symptoms

When Did Your Complaint/Symptoms Begin:

What Was the Cause of Your Symptoms:

Describe Your Pain:

How Have the Symptoms Progressed:

What movement or activity bothers you most:

Have You Had Surgery? *

Have You Been Told You Need Surgery? *

What Have You Found Offers Relief to Your Symptoms?

Are You Taking Medication for Your Symptoms?

What Other Treatments Have You Tried?

Truthful Representation: *

Upon entering my full name above, I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record.

In conjuction with my Neuro Therapy treatment and part of this consideration for my treatmnt, I, my heirs, executors, spouse, successors, assigns, offspring, agents, and representatives expressly release, hold harmless, and indemnify ARP Wave LLC, it owners, agents, employees, representatives, assignees, licensees, and invitees, from all liability for any treatmnts given.

I understand that I will be treated using ARPwave's propriety and patented treatment process/systems and I agree that I will not personally use or share any provided information/material with the intent to duplicate or replicate said system and protocols.