Note: All information provided is treated in the strictest confidence. The purpose of this document is to understand your overall health and well-being. If for any reason you do not wish to answer a question please leave blank.
Please list prescription medications you are currently taking or have taken in the last year.
Please list any over-the-counter medications you are taking or have taken in the last year
Please list any surgeries in the past
Diet & Liquid Intake
All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Please give any other information that you think is relevant.
If you have been diagnosed with any of the following complaints, you would not be a candidate for colon hydrotherapy treatments:
Cirrhosis of the liver
Congestive Cardiac Failure
Colon, Kidney or Liver Cancer
Diverticulitis (inflamed, medicated and suffering from symptoms)
Recent colon or rectal surgery
Severe cardiac disease
Severe prostate problems
Uncontrolled high blood pressure
Colon hydrotherapy and other treatments that Tummy Solutions may provide are not intended to replace the relationship with your primary health care providers and our consultation is not intended as medical advice. They are intended as a sharing of knowledge and information from our education, research and experience. The information and service provided is not used to prescribe, recommend, diagnose or treat a health problem or a disease. It is not a substitute for medical care. If you have or suspect you may have a health problem, you should consult your physician.
Tummy Solutions does not refund or transfer on any purchase for any reason. **All packages purchased will expire 12 months from date of purchase.
I understand that Tummy solutions has a cancellation policy which states that 24 hours cancellation is required for any appointment. Should I have an appointment on a Monday I understand I will need to cancel at the very latest on the previous Saturday before the equivalent time of my appointment on the Monday. If I cancel late (within the time indicated above) I understand my payment card will be charged the cost of the treatment as the cancellation fee or that I will lose that part of my pre-paid course of treatments unless Tummy Solutions is able to fill my cancelled appointment slot. I further understand that the full cancellation fee will be charged to my payment card if I do not attend my scheduled appointment and have not given Tummy Solutions sufficient notice as described above.
The procedure for colon hydrotherapy has been explained and I hereby give my consent for a digital examination and colon hydrotherapy to be performed on myself. I have read the above and confirm that I do not suffer from any condition that may prevent me from receiving colon hydrotherapy. I will keep Tummy Solutions and my therapist informed of any changes in my health.
I hereby certify that the above information given are true and correct as to the best of my knowledge.
Fm TSC1.rev 1 Confidential