Help Detox Me, INC

CES Device Authorization

Help Detox Me, INC

Step 1 of 2

Please complete the form below to be evaluated by a licensed healthcare provider.






Please select your intended use (select all that apply):
Depression Anxiety Insomnia
Are you 21 years of age or older?

Do you have a medical device implanted in your head or neck?

Do you have a pacemaker?

Are you pregnant?

May the device provider contact you regarding this authorization and/or important device related updates?