Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any of the following conditions? *

Select All That Apply

Pregnant

Organ Transplant Recipient

In a pain management program

Have a Pace Maker

Have an internal diabetic or pain pump

Have an untreated infection

Have a new physical injury/open wound

Have Fibromyalgia

Have an uncontrolled seizure disorder

Have a cancer diagnosis

Have any cardio vascular medical condition (including, but not limited to blood clots, Statins, DVT, pulmonary embolism, congestive heart failure, etc.)

None

If you've already purchased a Polaris Wellness Booster, is this/are these a new condition since your device was originally set up?

Yes

No

How did you hear about the Polaris Wellness Booster? *

Northern Star Counseling Website

Social Media: Facebook

Social Media: Instagram

Social Media: LinkedIn

Website Search

Personal Referral

A Practitioner

Other

Do you need to set-up a follow-up consult?

(This is for customers who have already purchased a device and have had their initial consult.)

Yes

No

I don't know

Do you need to purchase an additional consult?

(This is for customers who have used up their 2 Consults/Year.) Additional consults can be purchased for $50/30 minutes.

Yes

No

I'm not sure