Initial Cold Laser Detox Form
This ViralScoreTM form is for anyone with an initial cold laser detox appointment. Note: this form will take approximately 20 minutes to complete and must be completed in one sitting.
General Medical Information
The following information is provided to this facility for nutritional information. The information being sought is of a nutritional nature and not a medical diagnosis, treatment, disease prevention or health assessment. I hereby certify that I am not an employee, agent, or otherwise affiliated with the Federal Drug Administration, Health Canada, or a related agency. I further understand: According to the Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1), the term "Drug" is defined to mean; Articles intended for the use in the DIAGNOSIS, CURE, MITIGATION or PREVENTION of disease. In other words, to "say" that vitamin, mineral, trace or amino acids will have any effect on disease or symptoms thereof, that a particular nutrient then becomes a DRUG under the law as written. Therefore, any suggested nutrition is not intended as primary therapy for any disease or symptom, but is provided safely to upgrade the quality of foods delivered through the diet. By providing information you are aware that you are consenting for information to be used under the name ViralScoreTM-Nutritional Self- Evaluation. Information provided will be used for statistical gathering of data purposes only. No confidential information obtained will be used for any other purpose other then the ViralScoreTM program.
Previously Diagnosed Conditions
Acidosis-Chemical/Heavy Metal Toxicity Assessment
Please check all that have EVER affected your health.
Thyroid Symptom Survey
0- I do not have this.
Next three symptoms are for menstruating females. If this does not apply to you, then enter zeros.
Referring to your grand total:
0-9 Unlikely hypothyroidism
10-19 Mild hypothyroidism
20-29 Moderate hypothyroidism
30+ Severe hypothyroidism
Urgent Medical Information
Lectro Chi Premier Energy Ionic Foot Spa Consent
What to expect
The effective use of detoxification techniques can reduce the body burden through elimination of toxins and heavy metals. The Lectro Chi Premier Energy Ionic Foot Spa is a valuable tool to any individual seeking to reduce their body burden. However, it must be understood that any detoxification will be sucessful only with a well-planned and executed protocol.
Healthy individuals typically feel more energetic or experience a greater feeling of well being after a Lectro Chi Premier Energy Ionic Foot Spa session. Some individuals who are toxic and have a greater body burden may experience a dull headache, fatigue, thirst, hunger, light headedness, acrid smelling urine, or loose bowels. These are typical, symptomatic responses to detoxification.
The Lectro Chi Premier Energy Ionic Foot Spa will help in reducing the body burden by aiding in the elimination of toxins and heavy metals. It is important that you take responsibility for your health and play an active role in implementing a few suggestions to help expedite your journey to better health.
* Water: Stay hydrated. Hydration is important for proper body function.
* Rest: Your body is able to repair and heal while sleeping.
* Minerals: Take a full spectrum mineral supplement to replace depleted minerals and electrolytes.
* Supplements: Appropriate supplements need to be consumed for your unique physiological and neurological conditions.
* Nutrition: Eat a balanced diet of whole foods that are nutritionally beneficial.
* Movement: Exercise regularly; exercise is extremely important and needs to be performed at your level of health.
It is recommended that you consult with a health professional when concerned about a health related issue.
The Lectro Chi Premier Energy Ionic Foot Spa has not been evaluated by the Food & Drug administration and makes no claims to cure any illness or disease. Lectro Life Technologies, LLC does not diagnose, treat, or cure any physiological, emotional, neurological, or spiritual conditions. The information shared is for informaion purposes only. Opinions expressed should not be constructed as medical advice. The particulars of any person(s) concerns and circumstances should be discussed with your own qualified health care professional.
Office Policies Updated 9/1/2015
Our goal is to provide quality services in a timely manner. In order to do so, we implemented an appointment deposit policy. This policy enables us to better utilize available appointments for our clients. A nonrefundable deposit of $50 is required to make any appointment at our office. This $50 WILL be deducted from your total visit cost. The term nonrefundable includes cancelling/rescheduling in under 72 hours and no shows, please see policies below. Rescheduled appointments not falling in these two categories will not have to make a new deposit.
In order to be respectful of the needs of other clients, please call our office at least 72 hours in advance if you are unable to attend your appointment. Calling early in the day is appreciated. Rescheduling/cancelling early will give another client access to schedule an appointment sooner.
A ‘no show’ is someone who missed, was 20 minutes late or did not cancel/reschedule their appointment at least 72 hours in advance. No shows will be recorded in the client’s chart. If you fall in the no show category, then you will be asked to make a new deposit to reschedule.
Due to the fact all visits are prepaid, a $50 deposit will not be collected to schedule your appointments. Instead, if you do not call to cancel/reschedule at least 72 hours in advance or are considered a no show then you will lose that type of appointment(s) which is in question from your package.
All sales are final on products and services, no exceptions.
We strive to make our clients comfortable during their valued appointments. This includes the noise level. Please keep your cell phones on silent and kindly step outside our office to take a call. If you have children with you, then please bring something to keep them occupied that does not involve noise. All children must be accompanied by an adult throughout our office at all times, for their safety. We do have children’s books and prizes for good behavior!