Intake Form
Colonics
Please contact us at (510) 772-0947 via call or text to schedule your appointment before completing the intake form.
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Month
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Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Occupation
Emergency Contact
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
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Medication
Allergies
Supplements
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Name of Physician
First Name
Last Name
Physician's Phone Number
Please enter a valid phone number.
Physician's Address or Hospital
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recent Surgeries ?
Recent Vaccination
*
Yes
NO
If yes which one?
Date of Recent Vaccination
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Month
-
Day
Year
Date
Have you ever had a Colonoscopy ?
*
Yes
No
Date of Colonoscopy?
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Month
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Day
Year
Date
Have you ever had a Colonic/ Colon Hydrotherapy?
*
Yes
No
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What is your overall goal today?
*
How many bowel movements do you have a day?
How many meals do you eat in a day?
How many snacks do you have a day?
How would you describe you diet?
Vegan
Vegetarian
Pescatarian
Carnivore
Other
What do you eat in a day? Breakfast, Lunch, Dinner
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Contraindication
Please check all that apply
*
Severe Cardiac Disease (uncontrolled Hypertension or Congestive Heart Failure)
Aneurysm of any type
Severe Anemia
GI Hemorrhage/ Perforations
SEVERE Hemorrhoids
Recent Colon Surgery
Crohn's Disease
Cirrhosis
Fissures/Fistulas
Pregnancy
Abdominal Hernia
Renal Insufficiency
Ulcerative Colitis
Subject to Frequent Seizure
Pacemaker or Electronic Pump of any kind
Dialysis Patient
Cancer
Diverticulosis/ Diverticulitis
Acute Liver Failure
Rectal Tumors
Abdominal Radiation
Recent Abdominal Liposuction
Constant / Frequent Diarrhea
Other
I don't have any of the following Contraindications
Client Signature
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Submit
Submit
Should be Empty: