OXYGEN, ENERGY & LIGHT THERAPY
Experience a unique full body massage, total relaxation, stress relief
and an overall feeling of peace and wellness.
Do you have problems with: (Please check all that apply)
Many have reported improvement with the above problems as well as many other problems.
I understand that I should consult with my physician before use if I am recovering from surgery, have a serious infection or bleeding injury, have heart disease, bone fractures, a pacemaker, pregnancy or epilepsy.
Explain your present health:
Have you eaten within 30 minutes? Yes No
Please drink a glass of water before and after the therapy session!
IMPORTANT NOTE: I understand that with any session there are always unforeseen risks. I take full responsibility of my actions and do not hold AQUADVIDA USA LLC or CLEANSING WATERS LLC accountable for my decision to have a session.
I waive the right to any claims that I may have now or in the future in regards to the foot spa session I am about to experience.
By signing this sheet I authorize Nancy Spahr or other employees of Cleansing Waters to administer a session using the AquaVida® foot spa, Chi Machine, Hothouse, Advanced Electro Reflex Energizer or E-power. I understand these services are not intended to be substitutes for careful medical evaluation and treatment by a competent, licensed personal health care professional. The staff of Cleansing Waters, LLC are not physicians and therefore are not qualified to diagnose or prescribe. I agree not to hold anyone liable for any side effects that may occur during or after the use of the AquaVida® foot spa, Chi Machine, Hothouse, Advanced Electro Reflex Energizer or E-power.
Signature of Client (or Guardian if under age 18):
5501 East 71st Street, Ste 1A Indianapolis, Indiana 46220 (317) 259-0796