Forms FOOTBATH INTAKE FORMMASSAGE INTAKE FORMCOLONIC INTAKE FORMSAUNA INTAKE FORM FOOTBATH INTAKE FORM Step 1 of 3 - Contact Information 0% Date Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Number*Relationship 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 medical patient. 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 agree* Yes No 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 given individual. 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. Contraindications An ionSpa Foot Detox should NOT be used by: * Persons with a Pacemaker or any other battery-operated, electrical implant or heart beat regulation meds. * Persons who are on heartbeat-regulating medication; * Pregnant women and breast-feeding mothers. *Organ transplant recipients or person having an organ removed, especially the colon. *Persons taking any medication, the absence of which would mentally or physically incapacitate them, e.g., psychotic episodes, seizures, et cetera. IMPORTANT…….Users must also be aware of the following: *Persons should not wear metal, operate a computer or use a cellular phone during an ionSpa session * Persons with diabetes, congestive heart failure, or any other medical condition, should consult their Physician prior to using the ionSpa. *All ionSpa users should drink the Electro-mix supplement. Please follow usage instructions carefully to derive optimum results. *Users should be property hydrated prior to each ionSpa session. These statements have not been evaluated by the Food and Drug Administration. Please err on the side of caution. If you have doubts regarding a particular situation, contact your healthcare professional. I Agree* Yes No Date* Date MASSAGE INTAKE FORM Step 1 of 3 - Contact Information 33% Patient Name* First Last Age*Gender*MaleFemaleDate of Birth* Phone Number*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country OccupationReferred ByEmergency Contact InformationEmergency Contact Name First Last Emergency Contact NumberRelationship 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.Do you frequently suffer from stress? Yes No Do you bruise easily? Yes No Do you have diabetes? Yes No Have you had any broken bones in the past two years? Yes No Do you experience frequent headaches? Yes No Have you been in an accident or suffered any injuries in the past two years? Yes No Are you pregnant? Yes No Do you have tension or soreness in a specific area? Yes No Do you suffer from arthritis? Yes No Do you have cardiac or circulatory problems? Yes No Are you wearing contact lenses? Yes No Do you suffer from back pain? Yes No Are you wearing dentures? Yes No Do you have numbness or stabbing pains anywhere? Yes No Do you have high blood pressure? Yes No Are you very sensitive to touch or pressure in any area? Yes No If "yes" to previous question, are you on medication for this? Yes No Have you ever had surgery? Explain on next page comment section. Yes No Do you suffer from epilepsy or seizures? Yes No Do you suffer from epilepsy or seizures? Yes No Do you have any other medical condition or are you taking any medications I should know about? Yes No Do you suffer from joint swelling? Yes No Do you have varicose veins? Yes No Do you have any contagious diseases? Yes No Do you have osteoporosis? Yes No Do you have allergies? Yes No CommentsDate* Consent to Treatment of MinorBy my signature below, I hereby authorize rock wall complete wellness, to administer massage, bodywork or somatic therapy techniques to my child or dependent as they deem necessary.Date* COLONIC INTAKE FORM Step 1 of 3 - Contact Information 33% Date Name* First Middle Last Phone Number*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country OccupationDate Of Birth* Name of Physician First Last Patient InformationHave you had a colonic here? Yes No Is a family member a client here? Yes No How did you hear about us? Doctor Family Member Friend Ad Other Any Surgeries? Yes No Medications and Supplements you take (please list)Allergies (medication, food, environmental, etc.)What do you want to accomplish by coming here?Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Number*Relationship How many meals a day do you eat?Which meals? Breakfast Lunch Dinner Bowel Movement Per dayBowel Movement Per WeekBowel Movement Per MonthDo you use a stool softener, laxative or herbal laxative? Yes No My stools are soft, well formed alternates between constipation diarrhea loose, not watery difficult to pass large and hard small and hard often float thin, long narrow medium 1” x 4” large 2” wide x 6” length Order offensive usually occasionally little odor Color medium brown dark or black blood visible yellow brown greasy and shiny mucous dark brown greenish varies continued on next page Do you have trouble initiating a bowel movement? Yes No Is your stool too big or hard? Yes No Do you have abdominal discomfort or cramping accompanying bowel movements? Yes No Do you suffer from intestinal gas Yes No Do you have or have you ever had one or more of the following? history of gall stones hair loss dry mouth and eyes poor sleep habits muscle cramps joint stiffness poor memory nose bleeds fevers reduced appetite itching anus period of vomiting colds – often AlDS/HIV+ hepatitis fibromyalgia herpes 1,2,6,7 multiple sclerosis Parkinson’s disease epilepsy multiple sclerosis Parkinson’s disease epilepsy meningitis (bacterial or viral) blood transfusion chronic fatigue herpes simplex II (genital herpes) pain between the shoulder blades inflamed appendix herpes simplex II (genital herpes) pain between the shoulder blades inflamed appendix other Do You eat when nervous? gain or lose weight easily? get jittery when a meal is delayed? worry? feel insecure? have dental fillings? have a root canal? have silicone/saline breast implants? Are You disinterested in food bloating/Gas burping food Regurgitates feeling fullness after meals nausea after eating having painful and burning sensations after meals General headaches insomnia loss of weight dizziness fainting spells history of seizures fatigue enlarged thyroid double/blurred vision depression cancer cirrhosis Gastrointestinal colitis constipation Crohn’s disease ulcerative colitis diverticulitis diverticulosis gall bladder disease fissures/fistula inflamed appendix family history of colon cancer rectal bleeding hemorrhoids Respiratory shortness of breath chronic cough vomiting blood emphysema bronchitis asthma (wheezing) other Cardiovascular high blood pressure hardening of arteries angina (chest pain) poor circulation rapid heart beat irregular heart beat congestive heart failure liver trouble swelling of ankles Muscle and Joint arthritis bursitis low back pain neck pain swollen joints other Urinary kidney infection or stone painful urination prostate trouble kidney failure other Skin bruise easily dryness itching rash varicose veins other Women painful menstruation other Date* SAUNA INTAKE FORM Step 1 of 2 - Contact Information 50% Name* First Last Phone Number*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date* Gender* Male Female Referred by* 1) Drink plenty of water before entering the sauna. 2) Do not eat for 2 hours before entering the sauna. Interruption of the digestive process due to heat can cause nausea. 3) Drink plenty of water after ending the session and continue to do so for 1 hour after exiting the sauna. 4) Do not take any Vitamin C 2 hours before or after your session as this will cancel out any of the desired effects of the sauna. 5) The sauna will regulate the temperature at the level you have it set. If the sauna feels like it is getting hotter after you have been in it for 10-15 minutes, it really isn’t (see the temperature display panel). This is your body failing to keep normal body temperature at 98.6 degrees F, your body temperature begins to rise and you begin to feel hotter. *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.Date Emergency Contact* First Last Emergency Contact Phone Number*
