Foot Detox Intake Form

Bodi’Oasis Wellness Spa & Salon

3095 Marshall Hall Road, Bryans Road MD 20616

Ion Foot Detox Client Intake Form
Phone:
Name:
Date of birth:

Month Day Year
Date
Email:
example@example.com
How did you hear about us?
What is your main purpose in coming today?
What is your expectation for your visit today?
Have you had an Ion Foot Cleanse session before?

YES NO
Stress Level 1 – 10 (10 = very stressed):
What are your current health concerns?
Please list any recent surgeries or traumas:
Are you been treated by a Doctor or Health Practitioner now? If YES, please explain

YES NO
Please list medications taken for vital organs or a medical condition:
How many glasses of water do you drink per day?
What type of diet do you follow?
Frequency of physical exercise:
Type:
Is there any other medical information we need to know:
Please check off any of the following that are true for you:

I have a pacemaker or other battery-operated or electrical implant. I am on heartbeat regulating medication. I am pregnant or breast-feeding. I am the recipient of an organ transplant. I am having an organ removed. I have congestive heart failure. I have open wounds on my feet. I take medication for psychotic episodes or seizures, etc. I am currently undergoing chemotherapy or radiation. I have to have dialysis. I have epilepsy.
NOTE: If you checked any of these items, we cannot treat you for Ion Foot Detox at this time, unless you have a prescription from your health care professional. A Mineralization Foot Bath is safe, effective, and the same price.
Please read the following information and sign at the bottom:
- Persons should not wear metal, use a computer or cellular phone during and Ionic Foot Detox session.
- Persons with low blood sugar should eat before using the Ionic Foot Detox.
- Though not dangerous, persons having a metal joint implant may find exposure to the electromagnetic field generated by the Ionic Foot Detox to be uncomfortable. If discomfort is experience, the session will be stopped immediately.
- Persons taking prescription medication should take meds after or four hours prior to their session.
- Because the Ionic Foot Detox is designed to aid the body in eliminating toxins that the kidney and liver cannot eliminate on their own, as a general rule, it may be used by persons on dialysis or by those diagnosed with diabetes or congestive heart failure. However, persons with these conditions, or any other medical conditio n, should consult their physician prior to implementing the Ionic Foot Detox as part of their wellness program.
- In addition to toxins being pulled out of the bloodstream, valuable electrolytes (calcium, potassium, sodium, and magnesium) may also be purged from the body. To safeguard against this possibility, users are encouraged to drink and Emergen - C or have the re - mineralization session directly after their session.
Disclaimer: We do not make any claim to offer cures or treatment of any disease or illness. If you are sick, please consult with your doctor.

Acknowledgement: By signing below, you acknowledge that you have read and understand this document, and have received acceptable answers to all of your questions and consent to receiving and Ionic Foot Detox. You hereby agree to release Bodi’Oasis Wellness Spa & Salon from any liability or damage that may incur due to the use of the Magic Ion Cleanse.
Possible Side Effects:

The Ion Cleanse equipment is a detoxification treatment so those who have any degree of toxicity may experience some cleansing reactions because all individuals are unique, we cannot gauge or guess your reaction(s) to a treatment. Some individuals have experienced fatigue, headache, or other symptoms similar to a cold or flu. These symptoms will abate with time and subsequent treatments.
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