Forms

Footbath Intake Form

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Colonic Intake Form

Sauna Intake Form

Step 1 of 3 - Contact Information

33%

Name*
First Last
Phone Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Of Birth*
Date Format: MM slash DD slash YYYY
Emergency Contact Information
Emergency 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.
Initials*

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.
Signature*
Date*
Date Format: MM slash DD slash YYYY

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 Country
Date Of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Referred by*

Step 1 of 3 - Contact Information

Emergency Contact Information

Step 1 of 3 - Contact Information

Emergency Contact Information

Consent to Treatment of Minor

Step 1 of 4 - Contact Information

Patient Information

Emergency Contact Information

Step 1 of 2 - Contact Information

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Please be advised we are no longer using the mind body app. For appointments please contact our office to schedule appointments. Sorry for the inconvience.

972-771-8900