Colon Hydrotherapy intake form
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about us?
Do you have any of the following
Diabetes
High Blood Pressure
Cancer
Autoimmune disease
HIV
Hemorrhoids
HSV 2 (Genital Herpes)
What are your main concerns?
Bloating
Constipation
Diarrhea
Parasites
Indigestion
Gas
Inflammation
Do you have any gastrointestinal disorders? ( CHRONS, Gerd, IBS, SIBO etc)
Yes
No
If answered yes, please specify
Are you pregnant or nursing
Yes
No
Acknowledgement and Waiver
Purpose: I understand that colon hydrotherapy is a therapeutic procedure intended to cleanse the colon and may involve the infusion of water into the rectum and colon for the purpose of cleansing.
Voluntary Participation: I am participating in colon hydrotherapy voluntarily and of my own free will. I have been informed about the procedure, its benefits, and potential risks.
Health Information: I have provided accurate and complete information about my health history, including any medical conditions, allergies, medications, or prior surgeries.
Potential Risks: I understand that colon hydrotherapy carries certain inherent risks, which may include cramping, discomfort, nausea, and diarrhea. In rare cases, there could be the risk of infection, or other adverse reactions. I understand that these risks will be minimized by the qualified practitioner.
Confidentiality: I understand that the information related to my treatment will be kept confidential and will only be disclosed as required by law.
Release of Liability: I release the colon hydrotherapy practitioner, their staff, and the facility from any liability for any injuries, discomfort, complications, or other adverse effects that may arise from the procedure, except those resulting from gross negligence or willful misconduct.
Follow-Up Care: I understand that it may be recommended to schedule follow-up appointments for additional treatments or to address any concerns or complications.
I understand that all sales are final and non-refundable
I have read, understood, and agree to the above terms and conditions
Yes
Signature
Submit
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