Colon Hydrotherapy Intake and Clearance Form
About This Form
This intake form serves as a means to evaluate your current and recent medical status to ensure you are healthy to participate in colon hydrotherapy sessions at Rock Solid Health. You must complete all sections of this form and answer questions completely. For questions that do not apply, please answer accordingly. Dr. Valerie Chavez will review the information you provide and make a determination whether you are cleared or not cleared to receive colon hydrotherapy sessions. Dr. Chavez is not responsible for your overall medical care and serves only as a screening provider for colon hydrotherapy sessions at Rock Solid Health.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Is it okay to email you with any questions?
*
Yes
No
Phone Number
*
Is it okay to call/text you with any questions?
*
Yes
No
Occupation
Are you Active Duty Military or a Veteran?
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Verify Your Age
*
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
How did you hear about Rock Solid Health?
Please Select
Referred by Friend
Doctor Referral
Walk-in / Drive-by
Internet Search
Magazine Ad
Radio Ad
TV Ad
Newspaper Ad
Who referred you to Rock Solid Health? We'd like to thank them.
Contraindications
Have you had any of the following within the last six (6) months
Congestive heart failure / Heart condition
*
Yes
No
Currently in first or last trimester of pregnancy
*
Yes
No
Recent colon or rectal surgery
*
Yes
No
Ventral / Inguinal (abdominal) hernia
*
Yes
No
Anal fissure or fistula
*
Yes
No
Abdominal surgery
*
Yes
No
Liver cirrhosis
*
Yes
No
Severe hemorrhoids or rectal bleeding
*
Yes
No
Uncontrolled high blood pressure
*
Yes
No
Colon cancer
*
Yes
No
Renal (kidney) insufficiency
*
Yes
No
Intestinal perforation
*
Yes
No
Colitis or Diverticulitis
*
Yes
No
If you answered "Yes" to any of the conditions in the above question, please explain below. If you answered "No" to all of the above, please enter "None".
*
Do you suffer from any of the following conditions?
Digestive Disturbances
*
Yes
No
Constipation
*
Yes
No
Diarrhea
*
Yes
No
If you answered "Yes" to any of the conditions in the above question, please explain below.
Medications, Supplements, Allergies
Are you taking any Medications
*
Yes
No/None
Please list your medications here:
Are you taking any vitamins or supplements?
*
Yes
No/None
Please list the vitamins and/or supplements you take:
Are you allergic to any foods or medications?
*
Yes
No/None
What are you allergic to and what is the reaction/allergy?
Payment
*
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Clearance Form Processing Fee
Your receipt will be from Chavez Healthcare, PLLC. This purchase is final. No refund options are available.
$
35.00
Credit Card
Patient Acknowledgement
By signing below and clicking "Submit", you agree to the non-refundable processing fee. You also attest that you are providing current and accurate information for Dr. Chavez to make an informed decision about you receiving colon hydrotherapy sessions. Should any of your medical history or current health status change, you are responsible for notifying the staff at Rock Solid Health, as any changes may preclude you from receiving further colon hydrotherapy sessions. This form is valid for 12 months only at Rock Solid Health.
Signature
*
Today's Date
-
Month
-
Day
Year
Contraindications Present
Yes
No
GI Conditions Present
Yes
No
GoodUntilDate
-
Month
-
Day
Year
Submit
Should be Empty: