Ballancer Pro Consent Form Please enable JavaScript in your browser to complete this form. BALLANCER PRO CONSENT FORM Important Information: The Ballancer®Pro system is intended for use by people in good health. This system is not recommended for people who have heart problems, or vascular problems, have a condition requiring the use of any medical device, or have any condition that may affect their normal well-being. If you are, or may be, pregnant, consult with your physician before use.Do not use this system over insensitive or numb areas, or in the presence of poor circulation. Do not use if you have been diagnosed with blood clots, deep vein thrombosis or phlebitis. This system should not be used over swollen, inflamed areas or skin eruptions. Do not use in the presence of unexplained calf pain. Consult your physician prior to use. This questionnaire is to be completed by all clients before using Ballancer®Pro for the first time. Please answer the following by circling the correct answer (YES or NO): 1. Are you in good health?YesNoSpecify2. Do you have heart problems?NoYesSpecify3. Do you have vascular problems (problems with your circulation, veins, or arteries)?NoYesSpecify4. Do you use a medical device (or have one implanted) to treat a medical condition?NoYesSpecify5. Do you have any medical condition that affects your well-being?NoYesSpecify6. Are you pregnant?NoYes7. Do you have poor circulation?NoYes8. Have you ever been diagnosed with blood clots, deep vein thrombosis, or phlebitis?NoYes9. Do you have calf or leg pain that is unusual and/or the reason for which is unknown to you?NoYes10. Are any areas of your body numb or insensitive to pain?NoYesSpecifyIf you have a condition or risk factor listed above, or if the answer to question 1 is NO or if any of the answers in questions 2.-10. is YES you must obtain authorization from your physician before using the Ballancer®Pro. Client Declaration: I hereby affirm that I have answered the above questions truthfully to the best of my knowledge and have verified that I have none of the contraindications to using the Ballancer®Pro. If there is a change in my condition I will immediately inform the operator of the Ballancer®Pro device. I hereby affirm that I am using the Ballancer®Pro at my own risk. Print Name *Email *DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneSignature Clear Signature Submit
