• 2603 Oak Lawn Ave Suite 101 Dallas TX 75219
    Ph. (214) 219-4100 www.deNovoHC.com

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  • Patient Information

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  • Present Health

  • Health History

    A contraindication is a specific health condition in which a drug, procedure, treatment or surgery is inadvisable as it may be harmful to the health of the patient.
  • Describe what you typically eat



  • Patient Medications

    Be sure to include all medications, prescriptions, over-the-counter, dietary supplements and vitamins.
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  • *I understand that my practicioner relies on the medication information I provide to him/her for my care and that any medication misinformation can result in hospitalization or death.  I also understand that prevention of dangerous drug interactions and duplications of medications are a top priority for my safety.  By typing my name below, I acknowledge that the medication information I am providing is accurate and complete and I give permission for the facility to review my medication history.  

  • Patient Tobacco/Alcohol/Caffeine Usage

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  • Bowel Retraining Program

    For Bowel Retraining we generally recommend daily Probiotic, supplemental Fiber and a colonic plan that includes a colonic on two consectutive days for two weeks (with only a very light meal in the evening between) and then once per week for 8 weeks. 


  • By my signature below I understand that this facility uses FDA approved Colon Hydrotherapy Devices.  To date no studies have been conducted for this alternative and complementary modality. I am aware adverse events such as perforation, injury and illness have been alleged and claimed with the use of colon hydrtherapy services and enema kits.  Should I experience discomfort or pain, I am responsible for immediately stopping my session. 

     

    I have reviewed and discussed the contraindications listed above with the medical staff and I do not have any adverse health concerns and I wish to proceed with my colon hydrotherapy session(s).  

     

    The ansers I have provided are true, accurate and complete to the best of my knowledge. 

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