Colon Hydrotherapy Intake Form
Client Intake & Service Agreement for Colon Hydrotherapy (Colonic Treatment)
Email *
Your First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Mobile Number *
Are you currently under a Medical Doctor's Care? *
If "Yes", Please explain:
Are you pregnant? *
Do you have any history of Colon Cancer? *
Please put a "check" next to anything that is currently a health challenge.   *
Required
How often do you have a bowel movement? *
Do you have hemorrhoids or other rectal problems? *
How often do you use the following (including herbal)? *
Never
Annually
Monthly
Weekly
Daily
Stool Softner
Suppositories
Enemas
Laxative
Is there any family history of digestive problems, cancer or heart disease? *
What do you hope to achieve at this appointment? *
I hereby request and contest to the performance of Colon Hydrotherapy treatments on me (or on the patient named below, for whom I am legally responsible) by a licensed Colon Hydrotherapist who now, or in the future, treat me while employed by, working or associated with or serving as back-up for Sweet Waters Cleansing & Spa. By signing below, I show that I understand the above consent to treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. *
I understand that my "non-refundable deposit" of up to $35.00 will be used as my cancellation fee if I need to cancel my appointment with less than 24 hours notice. A new "non-refundable deposit of up to $35.00" will be required to hold my new appointment. This deposit will either be applied to my service at checkout or become  my cancellation fee if appointment is cancelled with less than 24 hours notice. *
How did you hear about Sweet Waters Cleansing & Spa? (If a friend referred you, please type name in "other")
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