Client Information Form

Contraindications for Colon Hydrotherapy

  • Severe cardiac disease; e.g. uncontrolled hypertension

  • Congestive heart failure or organic valve disease

  • Aneurysm

  • Severe Anemia

  • GI hemorrhage / perforation

  • Severe hemorrhoids

  • Cirrhosis

  • Carcinoma of the colon or rectum

  • Fissures / fistulas

  • Advanced pregnancy

  • Abdominal hernia

  • Recent colon or rectum surgery

  • Renal insufficiency

  • Advanced Crohn’s

  • Advanced ileitis

If you have any of the conditions listed above, Colon Hydrotherapy can NOT be done!

Cancellation Policy

Colon Hydrotherapy is an effective method of cleansing your large intestine (colon). Your therapist does not diagnose disease or prescribe medication. It is your responsibility to provide pertinent health information and to inform the therapist of any changes. The office will provide a form to assist you in collection from your insurance company, however, services rendered are payable at the time of service unless special arrangements have been made.

RELEASE: I understand and agree that Colon Hydrotherapy services provided by this State Certified Colon Hydrotherapist are provided pursuant to and in accordance with the laws of the State of Florida governing Colon Hydrotherapy. I agree to hold harmless, release and indemnify this State Certified Hydrotherapist with all relevant information necessary for the proper application of Colon Hydrotherapy and I expressly give my permission for this State Colon Hydrotherapist to provide such therapy. Failure to give 24 hours notice of cancellation will result in your being billed for the treatment.