Ionic Foot Detoxification Intake Form
This form is to be completed by all new clients. Once completed, the information is valid for 90 days. Every 90 days, a new form will need to be completed. When entering information, please make sure to be honest. The facilitator can best assist you if the answers to each question is truthful.
Is this your first time detoxing with Artistry Glam Esthetics
*
Yes
No
Do you have a pacemaker?
*
Yes
No
Do you have a battery operated or electrical implant?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you breast feeding?
*
Yes
No
Have you had an organ transplant?
*
Yes
No
Have you had an organ removed?
*
Yes
No
Do you take medication for seizures?
*
Yes
No
Do you take medications for psychotic episodes?
Yes
No
I
your name
certify that I HAVE NOT BEEN DIAGNOSED WITH ANY CONTRAINDICATIONS FOR AN IONIC FOOT BATH. If yes to any of these questions withdraws me from services.
Signature
THIS TREATMENT IS NOT MEANT TO DIAGNOSE, TREAT OR CURE ANY DISEASE!
Submit
Should be Empty: