Name_______________________________________________________

Address:____________________________________________________

City:____________________________State______Zipcode___________

Phone(H/W/C)______________________Email______________________

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:

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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.

Client Signature______________________________________Date________________