In Person Consent Form

Myotronics Continuing Education Consent Form

Doctor Name(Required)

Email(Required)

Practice Name

During the course you will be using Myotronics equipment for educational purposes. If you have any of the following contraindications, you will not be able to TENs.

Pregnant
On demand cardiac pacemaker
Over or in the proximity of cancerous lesions
Temporal Arteritis
Further care should be taken if the participant has suspected or diagnosed epilepsy, heart problems, or other implanted medical devices such as cochlear hearing aids, screws, plates or stunts.

If you have any other concerns or medical conditions, please consult with the lecturer prior to TENSing.

Consent(Required)

I fully understand the contraindications outlined above and authorize my participation.

I am not willing/able to participate in TENSing

Myotronics seminars, courses and events are recorded for consistency and marketing purposes.

I hereby consent and authorize an employee or agent of Myotronics to take photographs or motion pictures of me; or to produce videotapes, audiotapes, or other types of media productions that capture my name, voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

I authorize Myotronics to copyright the Materials, and I authorize Myotronics to use, reuse, copy, publish, display, exhibit, reproduce, and distribute the Materials in any educational or promotional materials or other forms of media, which may include, but are not limited to journals, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without further notifying me.

Doctor AGD #(s) to be used

Attendee Signatures

Full Name(Required)

Signature(Required)

Date(Required)

Full Name

Signature

Date

Full Name

Signature

Date

Full Name

Signature

Date

Phone(Required)

*Please provide best mobile contact # in case of technical difficulties during the course*