Aqua Detox Consent & Consultation Form/patient Form Page 2
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Metal joint implants
[ ]
Athletes foot
[ ]
Any type of foot fungus
[ ]
Urine canal obstruction
If you have ticked any of the above questions then the Aqua Detox Foot Spa treatment CANNOT be used.
5: Precautionary Check list
Please tick the appropriate responses
[ ]
Have you had anything to eat?
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Are you feeling extremely hungry, thirsty or feeling weak or dizzy?
Do you suffer from any of the following conditions?
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Low blood pressure
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Do you have any serious medical conditions?
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Low pulse rate
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Do you have any other infectious disease
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Low blood sugar levels (hypoglycemia)
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Do you have Liver problems?
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Low Body temperature
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Do you have Kidney problems?
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Diabetes
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Are you on kidney dialysis?
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Heart problems eg, angina, blood pressure,
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Are you HIV positive?
congestive heart failure
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Have you had any other major heart operation?
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Do you have injuries that may be aggravated by
the Foot bath
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Do you have any Blood clots that may be
aggravated by foot bath
Do you have Cancer?
[ ] Yes
[ ] No
If so, where and what type
If you have ticked any of these questions then it is advised to consult your GP prior to having aqua detox
session.
For anyone with low blood sugar levels (hypoglycemia )– see preparatory checklist.
Do you have any allergies e.g. to aromatherapy oils or fragrances?
[ ] Yes
[ ] No
If so, what from
Preparatory check list for Detox Foot Spa Treatment
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If you have low blood sugar have you eaten ?
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Are you properly hydrated ?
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If you take Prescription medication, has it been 4 hours before starting to the Detox Foot Spa
session
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If you have a medical condition (eg. dialysis, diabetes, congestive heart failure etc...) have you
consulted your GP and obtained consent for having Aqua Detox session.
[ ]
Have you had an electrolyte drink ( eg, coconut water )
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Have you had multivitamin/multimineral supplements.
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Have you removed all jewellery and all metal objects that you maybe carrying, including mobile
phones and other electrical devises
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