BodStim TM Prescription Form

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* 1. Are you pregnant?

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* 2. Do you have cancer?

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* 3. Do you have a pacemaker or ICD?

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* 4. Are you prone to rashes?

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* 5. Do you have deep vein thrombosis?

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* 6. Do you understand the BodStim TM Wiemspro EMS Suit is FDA cleared for augmenting the benefits of exercise particularly in helping build muscle tone and not for any medical disease or condition?

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* 7. Do we have your permission to publish and present your results in exercise improvement and circulating klotho gains, if any, including photos?

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* 8. Are you taking high doses of Niacin?

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* 9. Do you want an onboarding specialist to help you get started by Zoom? This is recommended.

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* 10. Do you want to have an online video consultation with a physicians or personal trainer fitness professionals?

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* 11. Do you agree to do exercise test of your choice at baseline and 12 weeks using the BodStim TM EMS Suit 2X or 3X a week for 1 hour for 12 weeks?

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* 12. Do you agree to purchase a Klotho blood test at baseline and 12 weeks at cost range $140 to $450 depending on volume on hand? Each test kit costs $870 and 3 hours set up at $127 an hour. Each test kit can handle 40 samples but must be used within days of opening.

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* 13. Contact information:

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