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First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Date of Birth

Month

Day

Year

What are your major health concerns?

Are you on any medications?

No

Yes

What conditions are the medications treating?

What do you do for employment?

If retired, please list previous career field:

For hypoglycemics only, when was the last time you had something to eat?

Are you pregnant or breastfeeding?

No

Yes

Are you on any mental health medications?

No

Yes

Do you have symptoms if you miss one or more doses?

No

Yes

Maybe

Are you on any blood pressure medication?

No

Yes

Does your blood pressure increase if you miss one or more doses of your medication?

No

Yes

Maybe

Are you on any blood thinning medications?

No

Yes

Do you take medication for irregular heart beat?

No

Yes

Are you currently taking a course of chemotherapy treatment?

No

Yes

The IonCleanse is part of a comprehensive health & wellness system and the information provided to you is solely for use as part of a self-improvement program. None of the information provided is intended to act as a substitute for medical advice, nor does it involve the diagnosis, prognosis, or prescription of remedies for the treatment or prevention of any disease or ailment.

I certify that everything on this form is true & correct to the best of my knowledge. I also understand that the IonCleanse is not a medical device and is not intended to diagnose, treat, cure or prevent any disease or ailment.

Agreement Date

Signature

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If under 18, name of minor:

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