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How much water do you drink per day?
Please indicate anything that is currently a health challenge or a past problem.
INFORMED CONSENT AGREEMENT
THE STATE OF NORTH CAROLINA HAS NOT ADOPTED ANY UNIFORM EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED PRACTITIONERS OF COMPLEMENTARY AND ALTERNATIVE MODALITIES. THIS STATEMENT IS FOR INFORMATIONAL PURPOSES ONLY SO THAT CLIENTS OF COLON HYDROTHERAPY AND COLON HYGIENE ARE INFORMED.
It is understood that the Registered Nurse / Colon Hydrotherapist RITA HAWTHORNE-RUNNELS makes no claims to cure or treat any medical conditions nor does she diagnose or prescribe any medications.
Rita Hawthorne-Runnels is a licensed Registered Nurse in the State of North Carolina operating under the license certificate #107414. Inquiries may be sent to: NC Board of Nursing, P. O. Box 2129, Raleigh, NC 27602. Verification may be obtained from the board’s website: www.ncbon.org or by calling (919) 881-2272
Rita Hawthorne-Runnels is a certified Colon Hydrotherapist by the Wood Hygienic Institute, Inc. Inquiries may be sent to: Helen M. Wood, Wood Hygienic Institute, Inc;, P. O. Box 420580; 2220 E. Irlo Bronson Memorial Hwy, Suite 11; Kissimmee, FL 34742-0580; firstname.lastname@example.org or by calling (407) 933-0009
The undersigned client agrees to seek competent medical or other professional services for conditions that require such counsel. He/She has been provided with a MEDICAL RELEASE FORM to be signed by their doctor prior to any treatments in order to be cleared for contraindications.
Description of therapy: Colon Hydrotherapy and/or Colon Hygiene
I acknowledge that (client name) __________________________________ has voluntarily contacted me for Colon Hydrotherapy and/or Colon Hygiene and state clearly that the dialogue between us is strictly confidential unless written permission is given to share records with other health care professionals.
CONTRACT FOR SERVICES WITH THE SANCTUARY
The services and educational information that I receive from The Sanctuary are to enhance and/or maintain my physical, emotional, and spiritual wellness. I also understand that The Sanctuary staff are natural wellness practitioners, not medical doctors and they do not practice medicine in this office.
The services of The Sanctuary are provided for the cleansing of the colon through Colon Hydrotherapy and/or Colon Hygiene. Ionic Foot Spa, Far Infrared Sauna, BioMat , AromaTouch Technique and Ear Candling are also available.
I am personally responsible for obtaining qualified medical assistance for the treatment of any disease or pathological condition(s) that I now have or may develop in the future.
It is the policy of The Sanctuary that all client records, conversations, messages, faxed documents, test results, testing procedures and treatment modalities shall be maintained in a strictly confidential manner, guarded in the strictest manner consistent with professional ethics, dignity and privacy of each and every individual.
The client is to be made aware that his/her treatment record, as generated within the facility of The Sanctuary is to be made available for private viewing by said client within the facility premises, upon a timely manner, but not to interrupt the normal operations of the facility.
These records may not be viewed by any other individual without the client’s written consent. Copies of any and all documents within the client’s record may be made at the expense of the client, but the client record may not be removed from the facility, except under subpoena.
I, the undersigned client, understand this information.
Consult 1 hour session / Consult ½ hour session
$ 80 / $40
Colon Hydrotherapy Initial Session (3 Hours, includes consult)
Single Colon Hydrotherapy Session
Package of 3 Colon Hydrotherapy Sessions
Ear Candling includes 2 candles (extra candles are $3)
AromaTouch Technique (Essential Oil Therapy)
T-Rex Whole Body Vibration Machine (initial setup)
$ 20 - $1/10 minute max session
BioMat Session (up to 30 minutes)
Returned checks charge
Appointments Not Cancelled 24 hours prior to appt.
Half the cost of service requested
No Show for appt.
100% of scheduled service
An initial appointment includes a consultation and colon hydrotherapy session will take approximately 3 hours. Follow up Single Colon Hydrotherapy session last approximately 1 ½ hours. There may be supplements recommended to complement and enhance the process of cleansing, and rebalancing the system. These supplements are an additional cost. All payments are due at the time of visit. We accept payments in cash, checks, and credit cards with a 3% convenience fee. Packages must be used within 6 months from the time of purchase. There may be times when promotional prices are offered. Only one discount can be used at a time.
Prices are subject to change without notice. PACKAGES: All packages are non-refundable and have no cash value. They cannot be used with any other offers and are not transferable. If at any time prior to your final payment you choose not to continue your sessions, you will be responsible for the remainder of your balance. IF YOU FAIL TO SHOW UP FOR YOUR SCHEDULED APPOINTMENT YOU WILL FORFEIT THAT SESSION.
Your time is valuable and we appreciate your understanding that our time is valuable as well. In the event you need to cancel an appointment, and as a courtesy to your therapist, please provide at least twenty-four (24) hours notification.. Appointments not cancelled twenty-four (24) hours prior to your appointment time will be subject to a 50% charge of your session price. No show appointments will be charged 100% of session price. THIS PAYMENT MUST BE MADE BEFORE ANY SUBSEQUENT SERVICES WILL BE PROVIDED.
I acknowledge that The Sanctuary and all staff members are NOT medical doctors. I understand that Rita Hawthorne-Runnels and staff members of The Sanctuary may provide nutritional and other health related information to help me attain and maintain my best health. All suggestions are designed to help me move towards my best state of health through personalized recommendations in lifestyle, exercise, health habits, and advanced nutrition. I understand that Rita Hawthorne-Runnels as well as staff members of The Sanctuary do NOT diagnose, treat or claim to cure any illness or disease. The services of The Sanctuary are provided for the cleansing of the colon through colon hydrotherapy, pre-colonoscopy preps, and others. I am responsible for obtaining qualified medical assistance for the treatment of any disease or pathological condition(s) that I now have or may develop in the future.
I have been made aware of all contraindications for Colon Hydrotherapy and Colon Hygiene and am here on this day and any subsequent visits by my choice and solely on my own behalf. I hereby release and discharge Rita Hawthorne-Runnels, The Sanctuary, from any and all claims which I or my agents ever had, now have, or may have relating to or arising out of services provided or recommendations that I have received. I acknowledge that it is my responsibility to consult with my physician or other health care providers relating to any disease or condition that I may have.
I have read this informed consent and understand it. I am not a minor (under the age of 18). By signing this agreement, I have read and understand the above policy regarding pricing, package pricing, and payment terms. Furthermore, I understand that if I do not show for an appointment I am responsible for 100% of the session cost, if the appt. is part of a package I understand that session will be forfeited. I am signing this release voluntarily.