ADDRESS

4010 Dupont Circle Suite 518
Louisville, KY 40207

PHONE

502-893-2006

Ion Foot Bath In-take

Ion Foot Bath In-take

CONFIDENTIALITY-  Any information exchanged on this form, or during a session, is strictly confidential. It will be used for the sole purposes of providing the best health care services possible. Please complete ALL questions.  If you are using your PHONE to complete this form, please rotate your phone so that you can see the "Next" button on the bottom right to go to next page. Make sure you hit SUBMIT at the end to transmit the form electronically to us. 
Name:*
Phone:*
-
E-mail:*
Address:
DATE OF BIRTH:
 / 
 / 
WEIGHT:
OCCUPATION:
HOW DID YOU LEARN OF OUR SERVICES?
ARE YOU NOW UINDER A DOCTOR'S CARE?
IF SO PLEASE EXPLAIN:

CHECK (“Y”) FOR YES AND CHECK (“N”) FOR NO


I (Full name) *

I understand that the following are  contraindications.

CONTRAINDICATIONS:
It is generally not recommended to use the machine
if you:
 Wear a pacemaker or any other battery operated
or electrical implant.
 Take heartbeat regulating medications or blood
thinners.
 Are a pregnant or lactating woman.
 Are an organ transplant recipient.
 Have undergone organ removal, especially the
colon.
 Are on a medication that, if absent from your
system, would mentally or physically incapacitate
you (e.g., psychotic episodes or seizures)


    (INITIAL) Cancellation Policy: I understand appointments cancelled in less than 48 hours’ notice is subject to cancellation fee. Missed or cancelled appointments in less than 48 hours are billed at the regular rate of the service(s) booked.

    Date :*
    Electronic Signature:*