Ion Foot Detox Form ION FOOT DETOX FORMNameD.O.BPhoneAddressCity/State/ZipEmailPlease fill in all information below. All information is kept strictly confidential.General Information:Have you ever had an Ionic Detox Foot Bath session before?YesNoIf yes, when was your last session?What are your reasons for having a session today?Current Medications you are taking?Any Allergies?Any Supplements?What is your diet like?Do you consume:coffeeteasodadairymeatgrainssugarfried foodfast foodalcoholtobaccodrugsAre you currently being treated by a Physician?Contraindications:Ionic Foot Baths are not suitable for everyone. If you have any of the following conditions, we recommend that you do not use the ion spa. If you have any other concerns regarding the use of the spa for health reasons, we recommend that you consult your doctor.Do you wear a pulse adjuster, pace maker, metal or other electromagnetism device?YesNoHave you undergone heart transplantation?YesNoDo you have hypertension?YesNoDo you have open wounds on your feet? (If so, you may soak your hands instead)YesNoAre you a blood cancer patient?YesNoAre you suffering from fever?YesNoHave you been diagnosed with a serious illness?YesNoIf yes, what?Women only: Are you pregnant?YesNoIs there any thing else that you should let me know about?I consent to the Ion Detox Therapy Foot Bath Treatment. I understand that these procedures are for the purpose of detoxification and are not intended to take the place of medical care or medications. I clearly confirm that I do not have any contraindications to the Ion Detox Therapy Foot Bath (as noted above). I understand that I take full responsibility for my own health and well-being.DateTimeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AM/PMAMPMCheckboxClient AcceptanceCLIENT FULL NAMESubmit
