Crystal Forests LLC
38 S. Market St. Suite 3
Frederick, MD 21701
Please print out and fill in this form prior to coming in for your appointment.
Crystal Forests Ionic Cleanse Foot Bath Disclaimer
Contraindicitons: If any of the following applies to you, you cannot use the Ion Cleanse.
The only exceptions would require a permission slip from your family physician.
Is the patient under 8 years old? Yes No
Do you have a pace maker, High Blood Pressure, Low Blood Pressure, Irregular heartbeat or are you on daily medication for your heart? Yes No
Any battery operated device to dispense medication? Yes No
An Organ Transplant or Recipient? Yes No
Any organs removed, especially a portion of the colon? Yes No
Take meds for an emotional disorder? Yes No
Treated for Epilepsy? Yes No
Pregnant or Nursing? Yes No
Are you a Type I Diabetic? Yes No
**Persons with low blood pressure should eat prior to treatment.
If you answered Yes to any of the above answers, please give more information here:
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My signature below confirms that I agree to participate in an ion cleanse session or series of sessions. I understand that this procedure does not treat or cure any disease. I have read the list of contraindictions and agree that none of them apply to me at this time. I fully understand that I will, in no way, hold the owner of this equipment Crystal Forests or Irene Richardson liable or responsible for any reason due to any complications that may arise from an ionic cleanse session. I am taking full responsibilty in having an ion cleanse session.