Colon Hydrotherapy Release and Contraindication Form

Colon Hydrotherapy Release & Contraindications
PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS BY SIGNING BELOW.
List reason for colon hydrotherapy session:
Contraindications for Use of Colon Hydrotherapy

Do you CURRENTLY or have you in the last 6 month experienced tany of the symptoms listed below?*

	Yes	No
Congestive heart failure
Intestinal perforation
Carcinoma of the rectum
Fissures or fistula
Severe hemorrhoids
Abdominal hernia
Renal insufficiency
Recent colon or rectal surgery
Abdominal surgery
First and last trimester of pregnancy
Cirrhosis

Initial below

Type your initials
I certify that I do not have any of the contraindications outlined above, and I acknowledgethat medical clearance is required if I have answered “Yes” to any.*
I understand and agree that it is my responsibility to inform Internal Harmony of any condition or changes in my health, now and on-going, which might affect my ability to exercise safely and with minimal risk of injury.*
Clients under 18 years of age must have parent/guardian consent to do colon hydrotherapy.
I have read the contents of this release/informed consent form carefully and state that I am not aware of any medical condition or other reason that would prohibit me from using this service. I understand that I will not be allowed to exceed the maximum allowable time. I have been given adequate instructions for the proper use of the equipment and understand the risks involved, and Im using at my own risk. I hereby agree to release the owners, operators, and manufacturers from any damages that I might incur due to the use at this facility, even if from negligence. I HEREBY RELEASE MY RIGHT TO SUE.
Name (type your full name)*

First NameLast Name
Signature (if on a smart device with a touch screen, use finger to sign)*

Clear
Date: (please type as mm/dd/yyyy )*
Should be Empty:

Colon Hydrotherapy Release & Contraindications