Canadian Aesthetic Academy Inc. IONIC FOOT BATH DETOXIFICATION CONSENT FORM Client Name: __________________________ Client Address __________________________ Client Phone number (H) ______________________ (C)_____________________ Date: _______________________ Please Answer the questions below: Question Yes No Not If yes, please explain sure Are you a Smoker? Do you have High Blood Pressure? Do you have Low Blood Pressure? Are you taking Medication for High or low blood pressure? Do you have a battery Operated Implants (ie Pace-Maker)? Have you received an Organ Transplant? Do you suffer from severe heart disease? Are you taking Heart Medications? Are you taking Blood Thinners? Do you have problem with Fluid Retention? Do you have Sleep Apnea? Do you have Joint Pain or Arthritis? Do you have Chronic Fatigue? Do you have Foggy Brain, or poor Concentration? Don you have Poor Circulation? Do you have Allergies? Do you have Eczema or Psoriasis? Do you have Hormonal Imbalance? Do you have Weak Immune System Are you pregnant or nursing? Are you diabetic? Do you have Epilepsy or Hemophilia? Do you have Type 1 Diabetes Are you undergoing chemotherapy or radiation? Are you under the age of 16 years old or older? Canadian Aesthetic Academy Inc. Client First Name: ______________________ Client Last Name: _________________________ Who should NOT use the machine? Please mark with an X if you fit any the categories listed below: Category Comments People with a Pacemaker or any other battery-operated or electrical implant Women who are pregnant or nursing People with transplanted organs. (Gallbladder or hysterectomies ok) Anyone who is on heart beat regulating medications or blood thinners People with Type 1 Diabetes. System People who suffer from epilepsy or hemophilia People undergoing chemotherapy or radiation People who have low blood sugar, should eat before using the footbath Children under the age of 16 years old. I ______________________ authorize Canadian Aesthetic Academy Aesthetician to perform Foot Ion Detox treatment on me. I understand that the treatment is purely elective. I also understand that this product is not intended to diagnose, treat, cure, or prevent disease. Canadian Aesthetic Academy Inc. makes no medical claims and makes no statements of validation. Always consult with your professional health care provider before beginning any health care regiment. Appointments are 1 hour long, which includes the Detox Foot Spa treatment of 30 minutes. The number of sessions needed will be determined on your first visit. _____________________________________ Client Signature Canadian Aesthetic Academy Inc. Information Sheet Benefits of Foot Detox Removes toxins and body waste products that can cause health problems Helps clear up bad skin Helps inactivate Viruses, Bacteria, Yeast and Fungus Assists in weight loss Headache relief Slows down aging and improves body flexibility Rejuvenates and energizes your whole body Enhances Nutrient Absorption Heavy metal removal Increase your Energy Help with faster recovery time for disease and injury Increase Oxygen in your body Helps relieve Pain and Tension Improve sleep Reduces Inflammation and Unwanted Fluid Retention Helps Balance Immune System AFTER TREATMENT SHOULD ACTIVITIES BE RESTRICTED? HOW FREQUENT SHOULD ONE HAVE FOOT DETOX? TWO TIMES a week approximately 2 to 3 DAYS INTERVAL, as its effect continues over the next couple of days after treatment. A TOTAL of 14 TREATMENTS (10 to 12 sessions may constitute a complete program for some people). NOTHING SIGNIFICANT may be noted immediately but CLOSE OBSERVATION and AWARENESS OF ONESELF will usually note IMPROVEMENT over the next couple of days after detox. Treatment Time Guideline Adults under 50 yrs:30 mins/session, once every 2 days for 10-14 sessions. Adults over 50 yrs: 30 mins/session, once every 3 days for 10-14 sessions Youth age16 yrs: 15 mins/session, once every 3 days for 6-10 sessions Disclaimer: This product is not intended to diagnose, treat, cure, or prevent disease. Canadian Aesthetic Academy Inc. makes no medical claims and makes no statements of validation. Always consult with your professional health care provider before beginning any health care regimen.
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