Colon Hydrotherapy Intake and Clearance Form

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 NameLast Name
Email Address*
example@example.com
Is it okay to email you with any questions?*

YesNo
Phone Number*
Is it okay to call/text you with any questions?*

YesNo
Occupation
Are you Active Duty Military or a Veteran?

YesNo
Date of Birth*

MonthDayYear
Verify Your Age*
Address*

Street Address

Street Address Line 2

CityState

Postal Code
How did you hear about Rock Solid Health?
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*

YesNo
Currently in first or last trimester of pregnancy*

YesNo
Recent colon or rectal surgery*

YesNo
Ventral / Inguinal (abdominal) hernia*

YesNo
Anal fissure or fistula*

YesNo
Abdominal surgery*

YesNo
Liver cirrhosis*

YesNo
Severe hemorrhoids or rectal bleeding*

YesNo
Uncontrolled high blood pressure*

YesNo
Colon cancer*

YesNo
Renal (kidney) insufficiency*

YesNo
Intestinal perforation*

YesNo
Colitis or Diverticulitis*

YesNo
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*

YesNo
Constipation*

YesNo
Diarrhea*

YesNo
If you answered "Yes" to any of the conditions in the above question, please explain below.
Medications, Supplements, Allergies
Are you taking any Medications*

YesNo/None
Please list your medications here:
Are you taking any vitamins or supplements?*

YesNo/None
Please list the vitamins and/or supplements you take:
Are you allergic to any foods or medications?*

YesNo/None
What are you allergic to and what is the reaction/allergy?

Payment*

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

MonthDayYear
Contraindications Present

YesNo
GI Conditions Present

YesNo
GoodUntilDate

MonthDayYear
Should be Empty:

Colon Hydrotherapy Intake and Clearance Form

About This Form

Contraindications

Do you suffer from any of the following conditions?

Medications, Supplements, Allergies

Credit Card

Patient Acknowledgement