Initial Intake Form
This intake form is for anyone with an initial Cold Laser Detox appointmentor Intuitive Wellness Guidance Consultation
Note: This form will take approximately 15 minutes to complete & must be completed in one sitting.
The following information is provided to this facility for nutritional information. The following being sought is of a nutritional nature and not a medical diagnosis, treatment, disease prevention, or health assessment. I hereby certify that I am not an employee, agent, or otherwise affiliated with the Federal Drug Administration, Health Canada, or a related agency. I further understand: According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "Drug" is defined to mean; Articles intended for use in the DIAGNOSIS, CURE, MITIGATION, or PREVENTION of disease. In other words, to "say" that vitamin, mineral, trace, or amino acids will have any effect on disease or symptoms thereof, that a particular nutrient then becomes a DRUG under the law as written. Therefore, any suggested nutrition is not intended as primary therapy for any disease or symptom but is provided safely to upgrade the quality of foods delivered through the diet. By providing information you are aware that you are consenting for information to be used under the name ViralScore TM - Nutritional Self Evaluation. Information provided will be used for the statistical gathering of data purposes only. No confidential information obtained will be used for any other purpose other than the ViralScore TM program.
Intuituve Wellness Guidance Consultation: I understand that no physician-patient relationship is established through my participation in this consultation. I also understand that this consultation is not psychotherapy. During this educational consultation, a list of available options or solutions will be described, but I agree that before undertaking any of these options or solutions, I will consult my physician or other health care practitioner whose care I am currently under. Recommendations are not meant to be taken as medical advice, nor is the information here complete enough by itself to make accurate or wise treatment decisions. Please talk with an appropriately trained healthcare provider before using these or other herbal medicines. I understand that an Intuitive Wellness Guidance Consultation is not a medical diagnosis, medical treatment, or medical advice; therefore, I understand that an Intuitive Wellness Guidance Consultation will not provide prescription, treatment or psychotherapy.
Please Rate Symptoms as follows:
0 - I do not have this | 1 - Mild | 2 - Moderate | 3 - Severe
Next three symptoms are for menstruating females.
If this does not apply to you then all zeros.
It is recommended that you consult with a health professional when concerned about a health-related issue.
The Lectro Chi Premier Energy Ionic Foot Spa has not been evaluated by the Food & Drug Administration and makes no claims to cure any illness or disease. Lectro Life Technologies, LLC and Be Intentionally Well, do not diagnose, treat, or cure any physiological, emotional, neurological, or spiritual conditions. The information shared is for information purposes only. Opinions expressed should not be construed as medical advice. The particulars of any person(s) concerns and circumstances should be discussed with your own qualified health care professional.
Office Policies Updated 4/1/22
Our goal is to provide quality service in a timely manner. To do so we implemented an appointment deposit policy. This policy enables us to better utilize available appointments for our clients. A nonrefundable deposit of $50 is required to make an appointment at our office. This $50 deposit WILL be deducted from your total visit cost. The term nonrefundable includes canceling/rescheduling in under 72 hours and also no-shows, please see policies below. Rescheduled appointments not falling in these two categories will be charged for a full session. The client agrees to charge the card on file.
To be respectful of the needs of other clients, please call our office at least 72 hours in advance if you are unable to attend your appointment. Calling early in the day is appreciated. Rescheduling/ canceling early will give another client access to schedule an appointment sooner.
A 'no show' is someone who missed their appointment, was 20 minutes late, or did not cancel/reschedule their appointment at least 72 hours in advance. No shows will be recorded in the client's chart. If you fall in the no-show category, then you will be asked to make a new deposit to reschedule.
Due to the fact that all visits are prepaid, a $50 deposit will NOT be collected to schedule your appointments. Instead, if you do not call to cancel/reschedule at least 72 hours in advance or are considered a no-show then you will lose that type of appointment(s) which is in question from your package.
All sales are final on products and services, with no exceptions. The client agrees to pay for services rendered at the time of service.
We strive to make our clients comfortable during their valued appointments. This includes the noise level. Please keep your cell phones on silent and kindly step outside our office to take a call. If you have children with you, then please bring something to keep them occupied that does not involve noise. All children must be accompanied by an adult throughout our office always, for their safety.
Lectro Chi Premier Energy Ionic Foot Spa Consent:
The effective use of detoxification techniques can reduce the body burden through elimination of toxins and heavy metals. The Lectro Chi Premier Energy Ionic Foot Spa is a valuable tool to any individual seeking to reduce their body burden. However, it must be understood that any detoxification will be successful only with a well-planned and executed protocol.
Healthy individuals typically feel more energetic or experience a greater feeling of well-being after a Lectro Chi Premier Energy Ionic Foot Spa session. Some individuals who are toxic and have a greater body burden may experience a dull headache, fatigue, thirst, hunger, light headedness, acrid smelling urine, or loose bowels. These are typical, symptomatic responses to detoxification.
The Lectro Chi Premier Energy Ionic Foot Spa will help you in reducing the body burden by aiding in the elimination of toxins and heavy metals. It is important that you take responsibility for your health and play an active role in implementing a few suggestions to help expedite your journey to better health.
• WATER: Stay hydrated. Hydration is important for proper body function.
• REST: Your body repairs and heals while sleeping.
• MINERALS: Take a full spectrum mineral supplement to replace depleted minerals and electrolytes.
• SUPPLEMENTS: Appropriate supplements need to be consumed for your unique physiological and neurological conditions.
• NUTRITION: Eat a balanced diet of whole foods that are nutritionally beneficial.
• MOVEMENT: Exercise regularly; exercise is extremely important and needs to be performed at your level of health.