* Required Information
Bladder Infection
Bloating
Blood in Stool
BM Painful /Difficult
Burning / Itching Anus
Constipation
Diarrhea
Infectious Disease
Hemorrhoids
Rectal Bleeding
Recent Barium Enema
Recent Colonoscopy
Strain
Use Laxatives
Vomiting
Date of Last Menstrual
Abdominal Hernia
Abdominal Surgery
Abnormal Distension
Acute Liver Failure
Anemia
Aneurysm - All Types
Carcinoma of the Colon
Cardiac Condition
Crohns Disease
Colitis
Dialysis Patients
Diverticulosis/Diverticulitis
Fissures & Fistulas
Hemorrhaging
Hemorrhoidectomy
Intestinal Perforations
Lupus
Pregnant
Rectal / Colon Surgery
Renal Insufficiencies
Taking medication's

I have not been diagnosed with any contraindications for colon irrigation. (See above*.) I am aware that this colon irrigation and enema device facility has a Licensed Medical Director that is not on site. I am aware adverse events such as perforation; injury and illness have been alleged and claimed with the use of Colon Irrigation and enema devices. Should I experience resistance during the nozzle insertion, I will immediately stop my session. If during the session I experience discomfort or pain, I am responsible for immediately stopping my session. I am aware that Certified Therapists do not insert, diagnose, prescribe and do not cure or treat any condition or disease. (See Back of form for more complete list of possible side effects.)

ATTENTION: PREPAID DISCOUNTED SESSION PACKAGES SOLD AS FOLLOWS:
1. All Prepaid Discounted Colonic Sessions are to be used within six (6 ) months of purchase.
2. No Show appointments are counted as a used session without a 12 hour advance cancellation.
3. Health History should be updated after twelve sessions. No Refunds! Non-Transferable!

Possible Side Effects and Precautions:
Increased Energy, Nausea, Vomiting, Cramping, Light Headed, Excessive Gas or Bloating, Overheating, Diarrhea, Headaches, Temporary Increase in Body Odor, Joint or Body Aches, Water Overtemperature, Perforation of Rectum/Colon, Hemorrhoids: (which may be irritated, inflamed or bleed),Increased Appetite, Over Hydration: (when multiple colonic sessions are done during short period of time) Irritation / Inflammation / Allergic Reactions of the rectum due to lubricant

Who would NOT be a candidate for colon hydrotherapy treatments?
If you have a concern about your health or the appropriateness of colon hydrotherapy you should consult a doctor .If you are pregnant or if you are diagnosed with diverticulitis, ulcerative colitis, Crohn’s disease, severe hemorrhoids, rectal or intestinal tumors, have undergone recent radiation therapy, have uncontrolled hypertension, congestive heart failure, or organic valve disease, have an aneurysm, blood clots, severe anemia, GI hemorrhage/perforation, cirrhosis of the liver, fissures or fistulas, have an hiatal or abdominal hernia, have had recent colon cancer or colon surgery or renal insufficiency then you would NOT be a candidate for colon hydrotherapy treatment unless authorized by your treating physician. Professionally administered colon hydrotherapy is generally safe if you are free of the above cited conditions/contraindications.

- DISCLAIMER - Every therapy, service, and product described or presented at HC3 Wellness Center is not a cure for any disease, ailment, or health condition. No medical claims are expressed or implied, either directly or indirectly, regarding the therapies, products, or services presented herein. We do not diagnose, treat, or prescribe. We are not licensed massage therapists so we require permission to touch you, if you desire, for services such as a Foot Detox Spa and possibly foot reflexology and/or an abdominal massage during your colonic.

I agree that the above information is accurate to the best of my knowledge. I give HC3 Wellness Center permission to evaluate (not diagnose, treat or prescribe) and provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do not have contraindications. I have reviewed the list of the contraindications for colon hydrotherapy and I hereby agree that I am responsible for my health and the services received here. I am aware of my 9th Amendment Rights to practice alternative health modalities.

Cancellation & Refund Policy

As a courtesy to other clients and therapists, a $35.00 cancellation fee is applied if not cancelled within the 24 hour window.

No-shows will be charged in full. Physician (RX) Fee is non-refundable and the prescriptions can only be used at HC3 Wellness Center.

Colonic sessions are non-transferable and non-refundable.

What if I arrive late? Arriving to your appointment late will simply limit the time for your session. Your session will end on time so that the next client will not be delayed. If you arrive late it is up to you whether you prefer to receive a shortened session or pay for the appointment and reschedule.

I agree to and understand the above Cancellation and Refund policy.

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