Ion Foot Bath In-takeCONFIDENTIALITY- 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:* First Last Phone:* - E-mail:*Address: Street AddressCityStateZip CodeDATE OF BIRTH: / / 201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900daymonthyearWEIGHT: OCCUPATION: HOW DID YOU LEARN OF OUR SERVICES? ARE YOU NOW UINDER A DOCTOR'S CARE? YesNoIF SO PLEASE EXPLAIN: CHECK (“Y”) FOR YES AND CHECK (“N”) FOR NO YES NODo you have open wounds on your feet? Do you have type 1 diabetes?Do you currently receive radiation therapy or chemotherapy?Do you have a pacemaker or any battery operated or electrical implant? Are you an organ transplant recipient?Did you have an organ removed, especially the colon?Are you pregnant or a breast feeding mother?Are you on heartbeat regulating medication?Are you taking medication, the absence of which would mentally or physically incapacitate you?Do you have any metal implants? e.g. a knee or hip replacement?You should consult with their physician if you have answered YES to any of these questions to see if this treatment would be appropriate for you. • Do not wear metal such as watches, use a computer or cell phone during a session. • If taking prescription medication, take them after or at least six hours prior to an Ion Cleanse session. • Users should be properly hydrated prior to and after each foot bath sessionI (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* (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:* SubmitReset
Ion Foot Bath In-takeCONFIDENTIALITY- 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:* First Last Phone:* - E-mail:*Address: Street AddressCityStateZip CodeDATE OF BIRTH: / / 201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900daymonthyearWEIGHT: OCCUPATION: HOW DID YOU LEARN OF OUR SERVICES? ARE YOU NOW UINDER A DOCTOR'S CARE? YesNoIF SO PLEASE EXPLAIN: CHECK (“Y”) FOR YES AND CHECK (“N”) FOR NO YES NODo you have open wounds on your feet? Do you have type 1 diabetes?Do you currently receive radiation therapy or chemotherapy?Do you have a pacemaker or any battery operated or electrical implant? Are you an organ transplant recipient?Did you have an organ removed, especially the colon?Are you pregnant or a breast feeding mother?Are you on heartbeat regulating medication?Are you taking medication, the absence of which would mentally or physically incapacitate you?Do you have any metal implants? e.g. a knee or hip replacement?You should consult with their physician if you have answered YES to any of these questions to see if this treatment would be appropriate for you. • Do not wear metal such as watches, use a computer or cell phone during a session. • If taking prescription medication, take them after or at least six hours prior to an Ion Cleanse session. • Users should be properly hydrated prior to and after each foot bath sessionI (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* (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:* SubmitReset
