AmpCoil Member Intake Form

Step 1 - Personal Info

Please fill out the following Intake form immediately. It only takes a couple of minutes. This information allows us to ensure clear communication to assist you during your AmpCoil journey. Failure to return this form and our other disclosure forms within 24 hours will result in a delay of shipping for your device.

Name *
Todays Date *
Todays Date
Shipping Address *
Shipping Address
Do you have a hearing aid, pacemaker, electronic implant, metallic implant, or are you pregnant or nursing? (These may be a contraindication for pulsed electro-magnetic field (PEMF) therapy) *
The best way we can serve you and improve the AmpCoil experience is by staying in touch! Do we have permission to occasionally check in with you to get feedback on your AmpCoil experience? *
Optimal wellness requires personal responsibility and personal commitment! Knowledge and support are also key assets to achieving your wellness goals! Visit our Wellness blog and Library at