• 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.
  • Is it okay to email you with any questions?*
  • Format: (000) 000-0000.
  • Is it okay to call/text you with any questions?*
  • Are you Active Duty Military or a Veteran?
  • Date of Birth*
     - -

  • Contraindications

    Have you had any of the following within the last six (6) months
  • Congestive heart failure / Heart condition*
  • Currently in first or last trimester of pregnancy*
  • Recent colon or rectal surgery*
  • Ventral / Inguinal (abdominal) hernia*
  • Anal fissure or fistula*
  • Abdominal surgery*
  • Liver cirrhosis*
  • Severe hemorrhoids or rectal bleeding*
  • Uncontrolled high blood pressure*
  • Colon cancer*
  • Renal (kidney) insufficiency*
  • Intestinal perforation*
  • Colitis or Diverticulitis*

  • Do you suffer from any of the following conditions?

  • Digestive Disturbances*
  • Constipation*
  • Diarrhea*

  • Medications, Supplements, Allergies

  • Are you taking any Medications*
  • Are you taking any vitamins or supplements?*
  • Are you allergic to any foods or medications?*

  • 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$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.
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    • Contraindications Present
    • GI Conditions Present
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