Colon Hydrotherapy Intake Forms


Please answer the questions below.
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Email *
Name *
Phone *
Address
Age *
Sex *
Height *
Weight *
Emergency Contact *
Why have you chosen colon hydrotherapy?
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Who is your primary care physician?
Date of your last physical examination
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Results of your last physical exam
Have you ever been diagnosed with ABDOMINAL MASSES? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with UNCONTROLLED EPILEPSY ? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with FISSURES OR FISTULAS? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with SEVERE ANEMIA? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with GI HEMORRHAGE? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with a GI ANEURYSM? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with a HEMORRHAGE? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with SEVERE CARDIAC DISEASE? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with HERNIA? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with CIRRHOSIS OF THE LIVER? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with COLORECTAL CANCER? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with INTESTINAL PERFORATION? If yes, please include the date of the diagnosis in the option  choice that says "other". *
Have you ever been diagnosed with CONGESTIVE HEART FAILURE? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with LUPUS? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with ULCERATIVE COLITIS or SEVERE COLITIS? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with CROHN's DISEASE (SEVERE OR ACTIVE)? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever had RECTAL SURGERY? If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had DIVERTICULITIS OR ACUTE DIVERTICULITIS? If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had RENAL INSUFFICIENCY? If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever been diagnosed with ACUTE PROSTATITIS? If yes, please include the date of the diagnosis in the option choice that says "other". *
Have you ever been diagnosed with HYPERTENSION? If yes please include the date of the diagnosis in the option choice that says "other". Please indicate whether you are on medication for hypertension. *
Have you ever been on  DIALYSIS? If yes please include the date of the diagnosis in the option choice that says "other". *
Are you taking ORAL steroidal anti-inflamatory medications? If yes, please indicate the name of drug and dosage, how long you have been taking them and the reason for taking in the option choice that says "other". *
Have you had ABDOMINAL SURGERIES within the last SIX MONTHS? *
Have you ever had a C-SECTION?   If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had GALLBLADDER SURGERY?   If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had GASTRIC BYPASS SURGERY?   If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had LAP BAND SURGERY?   If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had a HYSTERECTOMY?   If yes, please include the date of the surgery in the option choice that says "other". *
Have you ever had an ABDOMINOPLASTY?   If yes, please include the date of the surgery in the option choice that says "other". *
Please list any other surgeries:
How often do you have bowel movements? *
When you have bowel movements, is elimination complete? *
Do you use laxatives? If yes, please indicate in the answer choice "other" which ones, how many and for how long? *
Do you have any other symptoms or health problems not listed already? *
Do you experience any of the following symptoms?
Are you on a special diet?  If yes, please indicate diet in answer choice "other". *
Do you drink alcohol? *
Do you smoke? *
Supplements you are currently taking?
Please list any prescriptions you are taking and reason for taking them.
Have you had colon hydrotherapy before? *
Date of last colonic?
If you have had colonics before, did you use an open or closed system?
What is your primary reason for this service?
Is there anything else you would like to share with us?
Do you consent to using an electronic signature to sign this document? *
Patient Electronic Signature- Please type name into blank. This will serve as your electronic signature. *
Date *
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DISCLAIMER - COLON HYDROTHERAPY CONTRAINDICATIONS
In the state of Texas it is required under the current interpretation of the law that each patient be cleared for Colon Hydrotherapy by examination and prescription from an licensed MD or DO. The examination should include medical history, vital signs, abdominal palpitation, if warranted to rule out masses or lumps or extreme tenderness to the abdominal region, and also ruling out any contraindications to Colon Hydrotherapy. These contraindications include recent abdominal surgery (within 3 months), known cancer of the colon, uncontrolled hypertension, Ulcerative Colitis, Crohn’s disease, Diverticulosis or Diverticulitis in the inflamed states, fissures, hemorrhage, known pregnancy in the 1st and 3rd trimesters, Partial Colonectomy without cleared colonoscopy and treating Oncologist direct prescription. Our office does not perform this treatment in cases where the patient cannot eliminate the water by their own efforts. At this time, we are only accepting prescriptions after you have been seen by our medical director and we are presented with the form stating you are cleared for colon hydrotherapy and no contraindications are present.
But, ALL patients must have completed the same examination explained above with our medical director. NO EXCEPTIONS.
We do not insert the one time use rectal tubes for anyone. You must be able to do the insertion yourself or bring someone with you to do it for you.
We want the very best and safest treatment for you our valued client, with the greatest health benefits available.

I understand that In the state of Texas it is required under the current interpretation of the law that each patient be cleared for Colon Hydrotherapy by examination and prescription from an licensed MD or DO. The examination should include medical history, vital signs, abdominal palpitation, if warranted to rule out masses or lumps or extreme tenderness to the abdominal region, and also ruling out any contraindications to Colon Hydrotherapy. These contraindications include recent abdominal surgery (within 3 months), known cancer of the colon, uncontrolled hypertension, Ulcerative Colitis, Crohn’s disease, Diverticulosis or Diverticulitis in the inflamed states, fissures, hemorrhage, known pregnancy in the 1st and 3rd trimesters, Partial Colonectomy without cleared colonoscopy and treating Oncologist direct prescription. Our office does not perform this treatment in cases where the patient cannot eliminate the water by their own efforts. *
I understand that at this time, we are only accepting prescriptions after you have been seen by our medical director and we are presented with the form stating you are cleared for colon hydrotherapy and no contraindications are present. I understand that ALL patients must have completed the same examination explained above with our medical director without exceptions. *
I understand that you do not insert the one time use rectal tubes for anyone. I understand that I must be able to do the insertion myself or bring someone with me to do it for me.
Clear selection
Please provide your electronic signature indicating you understand the above disclaimer by typing your name into the blank below. *
Date *
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AGREEMENT AND POLICIES

Payments are due at the time of service.
A minimum of 24 hour notice is required for rescheduling/cancelling to avoid a full payment of the session. We may be notified by either email: houstoncomptherapies@gmail.com or by phone 713-298-0168 (call or text).
Packages are offered at a promotional rate and therefore are PRE-PAID and are NON-REFUNDABLE. They may be shared among family and friends AFTER they pay the fee.
Promotional packages have an expiration date:
Package of 3 expires in 6 months
Package of 6 expires in 12 months.
Please keep a record of your expiration date since we do not call you to remind you.

NOTE: Value paid for pre-paid packages have no expiration date. Only the promotional rate expires within the allocated time.

Referral Fee:
As a way to say “thank you” for referring to us, we gift you a complimentary 50% off colonic session or multi-session package. For this offer to be redeemable, the referral must purchase a package from us after seeing our medical director and presenting a valid prescription.



Please provide your electronic signature by typing your name into the blank below to indicate that you understand the policies above. *
Date *
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