Colonic Hydrotherapy
Intake Form

Please fill out this form completely if you are having a Colonic Hydrotherapy appointment. Please make sure you complete the form and click submit before leaving this page, otherwise your information will not be saved and submitted.

Name *
Name
Please provide us with the best contact phone number: *
Please provide us with the best contact phone number:
Have you ever experienced or been diagnosed with any of the following? *
Please check off all that apply:
Please check each item that you consume more often than twice each week:
Please agree to our policies and terms by checking the box below: *
I acknowledge that all the information I have provided is correct to the best of my knowledge. I understand that this is a cleansing and detoxifying therapy and that all colonic hydrotherapy sessions given are for the purpose of hygienic cleansing only. I also acknowledge that I have never had any surgery on my intestinal system, nor have I had any abdominal surgery or procedure within the last 2 months. If I have any questions about the appropriateness of this session for me, then I acknowledge that I have already discussed this with my physician.