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I understand that the attending technician is not an allopathic practitioner (MD) and does not portray his/her self to
be one, but is a wellness consultant and Ionic Footbath technician.
I fully understand the difference between, the practice of allopathic (conventional) medicine, nutritional/wellness
consulting and the practice of administering Ionic footbaths.
I fully understand that the services provided by the attending technician are not allopathic, but are
strictly the administration of Ionic footbaths in nature.
Any reference to patient or therapy is solely due to technical terminology and in no way implies that the client is a
I fully understand that the attending technician does not offer allopathic drugs, surgery, chemical stimulants,
traditional therapy, or any other conventional treatments. In addition, he/she does not diagnose, treat, or otherwise
prescribe for any disease, condition or illness.
I have solicited the Ionic Footbath technician service in good faith, exercising my free will and following the dictates
of my own conscious which allows me to select what I understand is most beneficial to my health.
If I desire any services not provided by the attending Ionic Footbath technician, which is my prerogative, I fully
understand that I should seek them elsewhere. A referral for such services may be arranged.
I presently seek council, advice, opinions, ionic footbath sessions or points of view and/or programs within the scope
of the attending technician’s wellness and stress reduction practice. I am fully aware and release the Ionic Footbath
technician to do the Ionic Footbath sessions.
I fully understand the services provided by the attending technician are not generally accepted and/or recommended
by allopathic doctors (MD’s) or other health care professionals. I realize that insurance payment may be possible,
but is highly unlikely.
By signing below, I acknowledge that I have read and understand all parts of this waiver and that I have had the
opportunity to ask questions with regard to all such procedures.
The Food and Drug Administration has not evaluated these statements. This product is not intended to diagnose,
treat, cure or prevent any disease.
I further affirm that I am not acting in any capacity other than a natural person desiring an Ionic Footbath. I further affirm that I
am not acting as an agent for the American Medical Association, any State Medical Association or Health Department, or any
National, State or Local healing arts group. I further state that I am not an employee or, agent for, or in any way associated with a
Foreign, Federal, State, or Local entity and am acting solely for myself in requesting and taking part in this session or series of
sessions. I further affirm that this session will not be used as an entrapment for any government, association, organization or
With the acceptance of this Consent agreement, I hereby waive and release myself and my heirs, executors and administrators,
from any and all claims of any nature what so ever and do acknowledge that I will use the services provided at my own risk. I
confirm that I have given accurate directions and that I am of legal age in this jurisdiction.
IMPORTANT…….Users must also be aware of the following:
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork, may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
I understand that as part of my health care, this organization originates and maintains health records
describing my health history, symptoms, examination and test results, diagnosis, treatment, and any
plans for future care or treatment. I understand that this information serves as:
As a courtesy to other clients and therapists, appointments must be cancelled 24 hours in advance. You are
charged in full for all scheduled appointments, unless the office is able to reschedule your time.
No-shows will be charged in full.
What if I arrive late? Arriving to your appointment late will simply limit the time for your session. Your session
will end on time so that the next client will not be delayed. If you arrive late it is up to you whether you prefer to
receive a shortened session or pay for the appointment and reschedule.
I agree to and understand the above policy.
*You should not get in the Ozone Sauna if you have any of the following:
Acute myocardial infarction, hyperthyroidism, cramp tendency, thrombocytopenia, ozone allergy,
chronic relapsing pancreatitis or if you are pregnant.