QUESTIONNAIRE FOR ION FOOT BATH TREATMENT

QUESTIONNAIRE FOR ION FOOT BATH TREATMENT

Please consider the following questions seriously. A YES answer would indicate that an Ion Detox Foot Bath may not be appropriate for you

YES NO 1 Do you have open wounds on your feet? 2 Do you have type 1 diabetes? 3 Do you currently receive radiation therapy or chemotherapy? 4 Do you have a pacemaker or any battery operated or electrical implant? 5 Are you an organ transplant recipient? 6 Did you have an organ removed, especially the colon? 7 Are you pregnant or a breast feeding mother? 8 Are you on heartbeat regulating medication? 9 Are you taking medication, the absence of which would mentally or

physically incapacitate you? 10 Do you have any metal implants. e.g. a knee or hip replacement?

You should consult with their physician if you have answered YES to any of these questions to see if this treatment would be appropriate for you. Question 10, though not dangerous, persons having a metal joint implant may find exposure to the electromagnetic field generated by the Ion Cell Cleanse to be uncomfortable, if you feel discomfort let me know immediately and we can lower the power setting to a more comfortable level.

Do not wear metal such as watches, use a computer or cell phone during a session. If taking prescription medication, take them after or at least six hours prior to an Ion Cleanse

session. Users should be properly hydrated prior to and after each foot bath session Take good quality mineral supplements to safeguard against loss of electrolytes.

I acknowledge having read all terms and conditions above and on the reverse side.

Your name_____________________________

Phone Number:__________________________

Email address:__________________________

Signature:

Date:_______

Disclaimer and Limitation of Liability

The procedures administered at North Shore Colonics or Colonics in Grayslake - by Lori Hirshman are non-medical procedures. They are not intended to be a treatment, prescription or therapeutic or corrective measure for human ailments, symptoms or conditions of any kind. Only your licensed physician can provide medical treatments. This business does not engage in diagnosis, prescription or treatment of physical or mental human ailments or conditions of any kind. Any medical complaints or requests for diagnosis, prescription or treatment of human ailments should be referred to your licensed physician

(1) In supplying the ionic foot bath, the Seller or Practitioner makes no warranties whatsoever, either express or implied, oral or written, in fact or by operation of law or otherwise, except as expressly set out in writing herein or in any purchase or user agreement entered into with the Buyer or User. The Seller or Practitioner specifically confirms that the ionic foot bath is not a cure for any diseases and no claims with respect to its uses for healing and cures has been made or intended to be made. Any results obtained by some users of the ionic foot bath are not guaranteed for other users of the ionic foot bath.

(2) The Seller or Practitioner and the Seller's or Practitioner's affiliates, including but not limited to retailers, importers, manufacturers, and their employees, servants and agents, shall not be liable to the Buyer or User nor to any other party for any liability, including without limitation strict liability, including liability for loss or damages due directly or indirectly to occurrences or consequences which relate to the use of the ionic foot bath, any losses or damages, including without limitation economic and consequential losses, or direct or indirect, incidental, exemplary and punitive damages whether in contract, tort or otherwise or any other claims or expenses in any manner resulting, including without limitation liability, losses or damages directly or indirectly from, or connected with, the supply of the ionic foot bath, or from the manufacture of the ionic foot bath and the discovery or elimination of any and all hazards, or from the failure to so discover or eliminate any manufacturing defects, or by reason of any action, omission, active negligence, passive negligence, including gross negligence or any error or omission in the manufacturing or supply of the said ionic foot bath and any misrepresentation, misstatement, imprudence, lack of skill or error of judgment of or by the Seller or Practitioner or its agents and servants or its affiliates in the sale or administering of the said ionic foot bath.

(3) The Seller or Practitioner assumes no liability whatsoever with regard to the Buyer's or User's compliance or failure to comply with directions for the proper use of the ionic foot bath as may have been supplied by the Seller or the Manufacturer.

(4) No supervisory actions will be required by the Seller or Practitioner with respect to the use of the ionic foot bath by the Buyer or User. The Buyer or User specifically confirms that he/she has been advised to use the ionic foot bath only in consultation with a physician as the Seller or Practitioner is not a qualified medical practitioner and is not in a position to advise the Buyer or User with respect to whether or not the ionic foot bath is an effective treatment for the Buyer's or User's medical conditions. The Buyer or User also confirms that there may be medical conditions that may be adversely affected by the use of the ionic foot bath.

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