Ionic Foot Detox Intake Form

DETOX FOOT BATH INTAKE FORM
Today's Date*

MonthDayYear
Date
Name*
Birthdate

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*
Have you ever had an Ionic Detox Foot Bath session before?*

YesNo
If yes, when?

MonthDayYear
Date
What are your reasons for having a session today? (Relax, Trying for first time, Detox purposes, etc)
Current Medications you are taking?*
Any Allergies?
Are you taking any Supplements?
What is your diet like? (Vegan, Veg, Omnivore, Keto, Intermittent fasting, etc)
Are you currently being treated by a Physician?

YesNo
If yes, what for?
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?*

YesNo
Have you undergone heart transplantation?*

YesNo
Do you have hypertension?*

YesNo
Do you have open wounds on your feet? (If so, you may be ineligible for this treatment)*

YesNo
Are you now or have you ever been diagnosed with cancer?*

YesNo
Are you suffering from fever?

YesNo
Have you been diagnosed with a serious illness?

YesNo
Are you pregnant?*

YesNoN/A
Is there any thing else that you should let me know about?
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?*

YesNo
If you do not authorize promotional use, do you understand that photos may still be taken solely for your medical history and progress tracking?*

Yes, I understand
Client Signature*

Clear
Date*

MonthDayYear
Date
Detox Specialist Signature

Clear
Should be Empty:

DETOX FOOT BATH INTAKE FORM