Medical Indications for Use of Colon Hydrotherapy
Contraindications for Use of Colon Hydrotherapy
Have you had any of the following in the past 6 months?
(Please note: If you answer yes to any of the answers below- please see your doctor. Colonics can not be prescribed at this time.)
Please check all that you're currently experiencing:
Colon Hydrotherapy Rx Requirements
Rx maintained on file for 6 months.
I acknowledge I have been advised that any appointment not cancelled within 24 hours of the appointment will be charged for the services scheduled. I also understand a credit card is required to make/ hold any appointment slot. Once Doctor has already written your Rx, if you cancel at any time, a $50 fee will be charged to credit card on file to cover the Rx and processing fees, and awaiting you to reschedule.
Form is complete- Please hit the submit button to send this form to Detoxity.