Ioncleanse Foot Bath Release Form

In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.

"*" indicates required fields

Patient Name*
Date of Birth*
Gender*
Home Address*
Do you have a heart pacemaker or any other battery operated or electrical implant?*
Are you pregnant or breastfeeding?*
Are you on medications to prevent rejection of a transplanted organ?*
Are you on mental health medications?*
If so, do you have symptoms if you miss one or more doses?*
Are you on blood pressure medication?*
Does your blood pressured increase if you miss one or more doses of your medication?*
Are you on blood-thinning medication such as Coumadin?*
Do you take medication for irregular heart beat?*
Are you currently taking a course of chemotherapy treatment?*
Consent*

Name
Signature Date*
This field is for validation purposes and should be left unchanged.