Health Consent Document

Health Attestation Form
Client Information

Please provide your personal details.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that the services I am requesting at Rectify Health are provided by a Professional Certified Colon Hydrotherapist trained in accordance with the standards of the International Association for Colon Hydrotherapy (I-ACT).

I understand that Rectify Health does not provide medical diagnosis, treatment, or prescriptions, and that colon hydrotherapy services are not a substitute for medical care.

I understand that the following are recognized contraindications for colon hydrotherapy; in other words, situations in which colon hydrotherapy cannot be performed for safety purposes:

- Severe cardiac disease (uncontrolled hypertension or congestive heart failure)
- Aneurysm
- GI hemorrhage/perforation
- Severe hemorrhoids
- Renal insufficiency (kidney disease)
- Carcinoma (cancer) of the colon or rectum
- Diverticulitis / Diverticulosis (requires physician prescription)
- Fissures / fistulas
- Pregnancy
- Abdominal hernia
- Recent colon or rectal surgery (within one year)

I understand that if I have been diagnosed with any of the above conditions, it is my responsibility to disclose that information to my colon hydrotherapist and decline services prior to receiving any colon hydrotherapy sessions.

I understand that I will self-insert the speculum with the colon hydrotherapist's guidance.

I understand that any information received during any of my colon hydrotherapy services is strictly for personal knowledge and is not intended to replace the direction, opinion, or prescription of my healthcare provider.

I understand that should I have any concerns about receiving colon hydrotherapy, I should consult my healthcare provider.
POLICIES ACKNOWLEDGMENT

I acknowledge and agree to the following Rectify Health LLC policies, which I have accessed and reviewed in full via the link provided:
- Cancellation, Rescheduling & No-Show
- Late Arrival Policy
- Payment & Fees Policy
- Prepaid Service Packages Policy
- Fragrance-Free Policy
Review Required: Please open this link, Rectify Health policies, and review before initialing below.
Policies Acknowledgment

I acknowledge that I have been provided access to the Rectify Health LLC policies, have had the opportunity to review them, and agree to comply with them. I understand that this informed consent shall remain in effect for all future services provided by Rectify Health unless and until I revoke my consent in writing, or unless Rectify Health updates or modifies its consent forms, policies, procedures, or scope of services in a manner requiring renewed acknowledgment or signature.
Initials

Initial here to confirm you have accessed, read, and agree to the Rectify Health policies.
DURATION AND SCOPE OF CONSENT

By signing below, I acknowledge that I have read this document in its entirety, understand its contents, and voluntarily agree to all terms contained herein. I understand that this consent applies to the initial session and all future sessions provided by Rectify Health LLC, unless superseded by a new signed consent form.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour Minutes
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Health Attestation Form

Client Information