Ionized Foot Bath Questionnaire

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How Did You Hear About Us/Referral Name?

Best Way to Remind You of Your Appointment?

Do You Have Any Battery Operated Implants (e.g. Pacemaker)?

Are You an Organ Transplant Recipient?

Are You Pregnant or Nursing?

Do You Experience Low Blood Sugar?

If You Are Prescribed Medication(s), Please List Below:

Have You Taken Medications for the Day?

Have You Been Diagnosed With Heart Disease or High Blood Pressure and Taking Medications?

Do You Currently Have Open Cuts on Your Feet or Ankles?

Do You Have Any Metal or Jewelry on Your Feet or Ankles?

The Ionic Foot Bath System is not a medical device and is not intended for use in the diagnosis of disease or in the cure, treatment, or prevention of disease. My Earthly Essentials makes no medical claims or statements of validation and takes no responsibility with operation of this device at the risk of the user. If you are uncertain of the precautions above, if you are ill or have been diagnosed with any disease, consult with your doctor. If you have a serious medical condition, the use of this technology should not replace any competent medical advice you are currently receiving. Our experiences have been that most people will use this technology while continuing to visit their usual medical professionals. The FDA has not evaluated this technology.

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