Ionic Foot Detox Intake Form

  • DETOX FOOT BATH INTAKE FORM

  • Today's Date*
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  • Birthdate
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  • Format: (000) 000-0000.
  • Have you ever had an Ionic Detox Foot Bath session before?*
  • If yes, when?
     - -
  • Are you currently being treated by a Physician?

  • lonic 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?*
  • Have you undergone heart transplantation?*
  • Do you have hypertension?*
  • Do you have open wounds on your feet? (If so, you may be ineligible for this treatment)*
  • Are you now or have you ever been diagnosed with cancer?*
  • Are you suffering from fever?
  • Have you been diagnosed with a serious illness?
  • Are you pregnant?*

  • I, the undersigned, consent to the lon 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)

  • Do you authorize Camellia Alise, LLC and its representatives to photograph or record you for educational, promotional, advertising, publication, or trade purposes, and release the company from any related claims or liability?*
  • Date*
     / /
  • Should be Empty: