Download Ion Detox Foot Bath Form

Natural Horizons Wellness Center
HEALTH HISTORY - ION-CLEANSE FOOT BATH
Name ____________________________________
Weight ____________Lbs.
Date______________ Date of Birth __________
Height __________
Referred by: ________________________
E-mail: _______________________________________ Chief Complaint(s) __________________________
Address __________________________________________________________________________________
Phones: Home ___________________
Work___________________ Cell ________________________
List the medications you are taking: ____________________________________________________________
Name of Doctor___________________________________
Areas of pain ___________________________
HAVE YOU HAD, BEEN EXPOSED TO, BEEN TREATED FOR, OR HAVE ANY OF THE FOLLOWING CONDITONS?
[ ] Acid Reflux
[ ] Abdominal Pain
[ ] Addiction
[ ] Allergies
[ ] Anemia
[ ] Antibiotics
[ ] Asthma
[ ] Amalgam fillings
[ ] Blood Clots
[ ] Body Odor
[ ] Boils
[ ] Breast Soreness
[ ] Breathing Complications
[ ] Bruises
[ ] Cancer: _____________? [ ] Constipation
[ ] Convulsions
[ ] Cravings: ________?
[ ] Diabetes
[ ] Digestive Problems
[ ] Dizziness
[ ] Disturbing Dreams
[ ] Ear Infections
[ ] Ear Itch
[ ] Epilepsy
[ ] Fatigue
[ ] Fever (elevated)
[ ] Frequent Infections
[ ] Gallbladder Problems
[ ] Gas/Bloating
[ ] Glandular Problems
[ ] Halitosis
[ ] Hair Breakage
[ ] Hay Fever
[ ] Headaches
[ ] Heart
[ ] Surgery/Pacemaker
[ ] Hyperglycemia
[ ] Hypertension
[ ] Indigestion
[ ] Lactating
[ ] Joint Disease
[ ] Liver Disease
[ ] Lung Disease
[ ] Menopause
[ ] Memory Failure
[ ] Migraines
[ ] Muscle Spasm
[ ] Nail Problems
[ ] Nausea/Vomiting
[ ] Nervous Conditions
[ ] Pregnant (current)
[ ] Palpitations/Flutter
[ ] Respiratory Problems
[ ] Reproductive Problems
[ ] Ringworms
[ ] Sciatica
[ ] Sexual Trans. Diseases
[ ] Smoker/Tobacco user
[ ] Skin Problems
[ ] Sugar Craving
[ ] Surgery
[ ] Swallowing Difficulties
[ ] Sweating {profuse}
[ ] Swollen Limbs
[ ] Thyroid Problems
[ ] Transplant Organ(s)
[ ] Varicose Veins
[ ] Vision Problems
[ ] Weak Limbs
[ ] X-Rays
[ ] Elaborate on any of the above_____________________________________________________________________
[ ] Other Diseases _________________________________________________________________________
Please Circle Any Of The Following Conditions That Are Considered Contraindications of
Ion-Cleanse Foot Bath Use:
Epileptic
Hemophiliac
Blood Thinner Medication
Pacemaker
Lactating
Pregnant
Metal inside body
Transplanted Organ(s)
Serious Disease
Physically Weak by Illness
DO YOU HAVE ANY CONTRAINDICATIONS FOR USING THE ION-CLEANSE FOOT BATH?
□ YES
□ NO
How did you hear about Natural Horizons Wellness Center? _______________________________________
Will this be the first time you’ve used an Ion-Cleanse Foot Bath? ________________
If no, when and where was your last use? _______________________________________
My goal for today’s session is _______________________________________
I authorize Teresa Owens to perform the Ion-Cleanse Foot Bath session.
Signature_____________________________________
Date _________________
Natural Hori zons Wellness Center
CONSENT FORM AND DISCLAIMER FOR ION-CLEANSE FOOT BATH
Name _______________________________________
Date______________________
The Ion-Cleanse Foot Bath is not intended to treat, cure, diagnose or prevent disease. It is also
not intended for any therapeutic, medicinal or diagnosis of any disease. All of the statements
here were not evaluated by the F.D.A. and have not been evaluated by an official clinical trial.
Information and statements made are for educational purposes and are not intended to replace
the advice of your attending doctor.
Individuals with epilepsy or hemophilia, those with a pacemaker or transplanted organs,
individuals on blood thinners, pregnant or lactating, anyone who has metal inside their body or if
you suffer serious disease and are physically weak SHOULD NOT USE the Ion-Cleanse Foot
Bath. It is not intended to be used by children under 10 years old. Use only under a physicians
instructions, direction or supervision.
Teresa Owens, CHT does not dispense medical advice, prescribe, or diagnose illness. She may
provide individual nutritional and supplement information as requested. The views and
nutritional advice expressed by Teresa Owens, CHT are not intended to be a substitute for
conventional medical service. If you have any medical condition, seek the advice of your
physician.
Signing my name means I have read, understand and agree with the foregoing statements, here
printed, and release and hold harmless Teresa Owens / Natural Horizons Wellness Center and
Ocean Cleanse of any and all liability from using an Ocean Cleanse ion unit.
≈≈≈≈≈≈≈≈≈
I __________________________________, have read the aforementioned and accordingly, I
authorize Teresa Owens to assist me in an ion-cleanse foot bath session. I further understand
that results may vary. I AFFIRM THAT I DO NOT HAVE ANY CONTRAINDICATIONS FOR
USING THE ION-CLEANSE FOOT BATH!
I am 18 years of age or older:
□ YES
□ NO
If no, I have received parental consent:
Name of legal parent/guardian___________________________________________________
Signature of legal parent/guardian: ________________________________________________
Signature_______________________________________
Date _________________
APPOINTMENT POLICY
We regard an appointment as a “contract”. We have agreed to provide care to you at an
appointed day and time – you have agreed to arrive and be ready for care at that
appointed day and time.
We require 48 hour notice for any change of appointment. Failure
to give us ample notice of a change may result in a charge to you
at the rate of $100.00 per hour of lost appointment time or for the
cost of your missed appointment.
We recognize that from time to time, unavoidable circumstances may result in a cancelled
or broken appointment with little or no notice.
We reserve the right to decide whether or not to charge for missed appointments on
a case by case basis.
____________________________________
Patient Signature
________________________
Date
Directions to Center
From the Beltway (495 North) and from D.C.
Take 66 West to exit 60 which is route 123 South (Chainbridge Road).
Once off the exit, you will come to a light.
Go 0.9 miles and take a right onto North Street (236 West) a one way street.
Stay in the right lane as North Street immediately becomes Main Street, which is a two
way street.
At the first street (Railroad Avenue) make a right.
Take an immediate left into the parking lot. Park anywhere.
Go into second entrance from the street and take elevator to 3rd floor.
From Route 50 East
Take route 236 East (Main Street).
Pass Judicial Drive on your right and take an immediate left onto Railroad Avenue just
before the Main Street Auto Repair sign.
Take an immediate left into the parking lot. Parking anywhere.
Go into second entrance from the street and take elevator to 3rd floor.
From Richmond Area
Take 95 North to Beltway (495 West) toward Tyson’s Corner.
Take 66 West to Exit 60 (123 South/Chainbridge Road).
See directions above (From the Beltway).
OR
Take 95 North to Beltway (495 West) toward Tyson’s Corner.
Take Little River Turnpike Exit (236 West to Fairfax).
Continue West on 236 for several miles through Old Town Fairfax.
236 curves around to the left becoming North Street.
You will come to the intersection of North Street and 123 South (Chainbridge Road)
(Post Office is on the right).
Cross Chainbridge Road and go 0.4 miles to Railroad Avenue and take a right and an
immediate left into the parking lot. Park anywhere. Go into second entrance from the
street and take elevator to 3rd floor.