IONIC FOOT BATH DETOXIFICATION CONSENT FORM by liaoqinmei

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									         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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