Consultation Intake Form

Terms of Treatment: I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder and does not prescribe medical treatment or pharmaceuticals. It has been made clear to me that colon hydrotherapy is not a cure or substitute for medical examination or diagnosis and that it is recommended that I see a physician for any ailments that I might have. I acknowledge that I have fully and honestly disclosed my health history to the therapist. I agree that the therapist is helping me with naturl hygiene at my request and is not diagnosing, nor treating disease, nor practicing any form of medicine.

A contraindication is any indication or symptom that makes it inadvisable to use a particular therapy. The following are contraindications for colon hydrotherapy. If any of the following apply to you, we are not able to treat you with colon hydrotherapy at the present time.

If you have any of these contraindications you may still be eligible to receive colon hydrotherapy once they have subsided or been eliminated or if you are under the order, guidance and supervision of a qualified physician.

  • Cancer of the Colon or GI (gastro intestinal) Tract
  • Acute Abdominal Pain
  • Recent History of Gl or Rectal Bleeding
  • Congestive Heart Failure
  • Uncontrolled Hypertension
  • History of Seizures
  • Carcinoma of the Rectum
  • Vascular Aneurysm
  • Epilepsy or Psychosis
  • Cirrhosis
  • Intestinal Perforation
  • Recent Colon Or Rectal Surgery
  • Recent Heart Attack
  • Fissures or Fistula
  • Pregnancy
  • Ulcerative colitis
  • Acute Crohn's Disease
  • Rectal or Abdominal Tumors
  • C-Diff ( Clostridium Difficile)
  • General Debilitation
  • Renal Insufficiency
  • Severe Hemorrhoids
  • Abdominal Surgery
  • Abdominal Hernia
  • Diverticulitis

Since the therapist is not licensed to diagnose disease states, I, the client take full responsibility for the status of my health and choose of my own free will to go ahead and have a colonic session performed. I, the client, also agree to let the therapist know of any changes to my health status with regard to future bookings.

(It is advisable if you are not aware of the status of your health at this time to seek out the services of a competent physician prior to booking a colon hydrotherapy session)

By pressing the Submit button above I am agreeing to all of RA's previous Disclaimer's.

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