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Blue Ridge Natural Healing

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Ionic CLeanse Release Form

First name*

Last name*

Address*

Phone*

Email*

Any major health problems*

List any medications currently taken*

What kind of work do you do?*

Do you have a pacemaker or any other electrical implant?*

Yes

Have you ever had an organ transplant or organ removal?*

Yes

Are you pregnant or breastfeeding?*

Yes

Are you on a blood pressure medication?*

Yes

Does blood pressure rise if you miss one or more doses?*

Yes

Do you take medications for heart disease?*

Yes

Are you on any blood thinning medication?*

Yes

Are you a Hemophiliac?*

Yes

Are you currently taking a course of chemotheraphy treatment?*

Yes

The Ionic Cleanse is not intended to treat, cure, prevent, or diagnose any disease or ailment. It assists your body to rebalance its bio-energy fields, and stimulates the body for self-detoxification. It can help you to Regain Health and Vitality. Many people report feeling more comfortable & having increased energy after only a few sessions.

I certify that everything on this form is true & correct to the best of my knowledge.

Signature*

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Date*

Month

Day

Year