Sacred Waters Wellness Arts Studio
Colon Hydrotherapy Intake Form
Street Address Line 2
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Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
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Saint Vincent and the Grenadines
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Turks and Caicos Islands
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Isle of Man
US Virgin Islands
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Weight - Best Guest
Which service(s) are you here for today?
Holistic Health Coaching
Prescreening for Contraindications
Please review the medical conditions below and check all that applies to you. It is important to inform us of any medical conditions that may be contraindicated for colon hydrotherapy. If you have been diagnosed with any of the following conditions you may not be a candidate for Colon Hydrotherapy. In certain cases we may require a written prescription or letter from the appropriate health care provider to proceed.
Abdominal Surgery (within 12 weeks)
Acute Liver Failure
Cardiac Conditions (uncontrolled or congestive heart failure)
Hemorrhoidectomy (removal of hemorrhoids-a doctor's release may be necessary)
Pregnancy 3rd Trimester
Rectal/Colon Surgery (After 12 weeks a prescription for colon hydrotherapy should be obtained)
None of the above applies to me
If diagnosed with any of the above please provide a brief explanation:
The items below are NOT contraindications for colon hydrotherapy, however, if any items below applies to you please check.
Blood In Stool
High Blood Pressure (controlled)
Fever or Flu like symptoms
Shortness of Breath
None of the above applies to me
What is your primary reason for Colon Hydrotherapy?
Have you ever had professional Colon Hydrotherapy before?
If yes, specify date and where:
Do you understand why it's recommended to do a minimum of 2 sessions (when it's your first time or when constipation is indicated)?
How often do you have a bowel movement? i.e. 1-3 daily, 3-4 weekly, every 2 weeks, etc...
Are you taking any medications which may weaken the intestinal walls?
Have you ever had a colonoscopy exam?
If yes, specify date and where:
Have you had a surgical procedure within the last year?
If applicable, please explain details of surgery within last year here:
Any diagnoses of chronic disease or illness not listed above?
Are you currently under a doctor's care for any specific medical condition?
Do you have any other physical complaints or symptoms not listed above? If yes, please explain:
How do you rate the overall quality of your health?
Excellent - never sick, no complaints or symptoms
Good - sick once per year, minor complaints/symptoms
Fair – occassional sickness, fatigue, minor complaints, symptomatic
Poor - chronic symptoms, stressed, fatigue or weakened symptoms
What improvements do you want to make for your health and wellbeing?
Are you open to learning more about holistic health or alternative medicine and how it may assist you in improving your health?
Please check all that you consume regardless of frequency:
None of the above
Do you take any vitamin or dietary supplements? Please reply YES or NO. If yes, please indicate what you take:
Do you take any medications daily? Please reply YES or NO. If yes, please list the conditions only:
If there is one thing that you could do to change your health, what will it be?
Contraindications - Informed Consent
I, the undersigned, have been informed of contraindications and I have not been diagnosed with any contraindications for colon irrigation (as listed above). I also understand that it is my responsibility to be aware of any medications I take and their side-effects. I'm currently not taking any medications that may weaken my intestinal walls.
Colon Hydrotherapy - Informed Consent
I, the undersigned, am in full agreement that colonic irrigation is not a proven method, cure or treatment of disease or condition, nor has it been portrayed as such. Colon irrigation in this facility is a self-administered procedure where I, as the user of the device, am solely responsible for my own actions and release liability regarding my health issues. The device being utilized in this facility is a FDA registered Class II gravity device that can be used to do endoscopic procedures. I understand I will self insert my own speculum and will be in full control of the procedure. I am aware not all states have laws governing the use of colon irrigation/enema devices. The facility I have chosen is aware of the laws governing the facility at the time I sign this waiver of consent and that at anytime those laws can change and neither I, my family, nor my representative(s) will hold the equipment manufacturer, facility or their employees responsible for my personal choice to receive colon irrigation at this facility nor hold them liable for any changes or variations of the law after the time of my dated signature below. All results of my session(s) are contributed to research and the utilization in future programs of Self Health Aid, while preserving my privacy, I waive any liability on behalf of the technician serving me.
Missed Appointment Policy
A 24-hour cancellation notice is required for each appointment with no exceptions except for an extreme emergency. If you do not show up for your appointment or do not give the required notice we charge the full amount for all appointments with no exceptions. Confirmation calls are a courtesy. We are able to email or text an appointment reminder upon your request. Additionally an appointment card will be give upon your request for any upcoming appointments. It is your responsibility to arrange your activities so that you can make the time you reserved. If you are late, we will do our best to accommodate you through the end of your scheduled time. If there is insufficient time to provide your scheduled service, your appointment will be forfeited so we may keep our commitment for following appointments. We truly value your time and ours and want to serve each client with our best service.
I, the undersigned, agree to the above policy and will pay in full for any appointments that I schedule and fail to show without the required notice. If I choose to reschedule, without providing a 24-hour notice I will pay the rescheduling fee of $35.
Please check here to agree and accept terms.
Offers + Promotions
NOTICE: Special offers and series programs have an expiration date. Services must be completed within the terms of the purchase agreement in order for the series discount to apply . By purchasing and using our services you understand and agree to the terms and policies. If you are not clear about any terms or policies please let us know prior to proceeding. It is our policy that all sales are final unless otherwise specified in writing.
Please sign full name below affirming you have read and agree to the terms above.
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