Intake Form

Welcome to Our Private Membership Association

We're delighted you're considering becoming a valued member of our Private Membership Association (PMA). Our community is dedicated to providing personalized services focused on holistic wellness, cognitive health, and overall well-being through innovative therapies and advanced technologies.

By becoming a member, you’ll gain exclusive access to our specialized therapies, resources, and support tailored uniquely to your individual health and wellness goals.

To join, please complete the Membership Intake Form below. We look forward to welcoming you into our community and supporting you on your journey toward greater clarity, balance, and wellness.

Let’s Begin Your Healing Journey Together.

Full Name
Gender
Email
Do you currently have or have you ever been diagnosed with any of the following conditions?
Do you have any implanted medical devices (e.g., pacemakers, cochlear implants)?
Are you currently pregnant or breastfeeding?
Do you take any medications that cause photosensitivity (e.g., certain antibiotics, diuretics, or NSAIDs)?
Do you have a history of light therapy treatment?
Waiver, Consent, and Disclaimer Acknowledgement of Information I understand that Near-Infrared (NIR) therapy is a non-invasive procedure that uses specific wavelengths of light to potentially support cognitive, neurological, and physical health. I have provided accurate and complete information about my medical history and current health status. Potential Risks and Side Effects I understand that potential risks and side effects of NIR therapy include, but are not limited to: Mild headaches Temporary discomfort or irritation Light sensitivity No guaranteed results for my condition(s). Waiver and Release of Liability I hereby release and hold harmless the service provider, its employees, agents, and representatives from any and all claims, liabilities, or damages arising from or connected to my use of the NIR helmet therapy, except in cases of gross negligence or intentional misconduct. I acknowledge that I have been informed of the potential risks and limitations of this therapy and have had all my questions answered to my satisfaction. Not a Substitute for Medical Advice I understand that this therapy is not intended to diagnose, treat, cure, or prevent any disease and does not replace traditional medical treatments. I agree to consult with my primary healthcare provider regarding the use of NIR therapy in conjunction with my existing treatments. Consent to Proceed I consent to undergo NIR therapy as described and agree to follow the recommended guidelines provided by the provider.
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