Clean Colonic, LLC


Date of Birth: _________ /_________/_____________      Age: ___________      Height: _______________    Weight: ____________________

Address: ____________________________________________City: _________________________  State: __________  Zip code: _______________

Cell Phone: ____________________________________________Cell Provider ______________________________________ 

Email: __________________________________________________    Referred BY:__________________________________________

Primary Care Physician: ___________________________________________________________   Phone: __________________________________

Emergency Contact: _____________________________________  Phone: _____________________________  Relation: ____________________


What is a contraindication? (contraindication) A contraindication is a specific health condition in which a drug, procedure, treatment, or surgery is inadvisable, as it may be harmful to the health of the patient.

Please CHECK and DATE if any experience with the following:                             Please CHECK any that apply:

________ Abdominal Hernia                       _________ Dialysis Patient                                            _______ Blood in Stool

________ Abdominal Surgery                     _________ Diverticulosis/Diverticulitis                    _______ Colonoscopy

________ Abnormal Distension                  _________ Fissures / Fistulas                                      _______ Use Laxatives

________ Acute Liver Failure                      _________ Hemorrhages  (internal/external)        _______ BM Painful/Difficult

________ Anemia                                            _________ Hemorrhoidectomy                                    _______ Burning/Itching Anus

________ Aneurysm                                       _________ Intestinal Perforations                              _______ Constipation/Diarrhea

________ Cancer (type: _____________)         _________ Lupus                                                             _______ Vomiting ______Bloating

________ Cardiac Condition                         _________ Pregnant (due date ____________)             _______ High Blood Pressure

________ Crohn's Disease                             _________ Rectal/Colon Surgery                                _______ Infectious Disease

________ Colitis                                               _________ Renal Insufficiencies                                  _______ Bladder Infection

                                                                                        _______ Hemorrhoids

*I have not been diagnosed with any contraindication for colon hydrotherapy.     INITIALS ___________________

READ and INITIAL: I am aware that this Center uses FDA Registered Medical Devices for Colon Hydrotherapy and only uses disposable sterile nozzles or speculums. Although all therapist(s) on staff have certificates showing they have completed Device Training, they may not be required to be state licensed or have a degree in health care. This center doesn't have a licensed medical director on site. No studies have been conducted for this alternative and complementary modality. I am aware adverse events such as perforation, injury, and illness have been alleged and claimed with the use of colon hydrotherapy devices and/or home enema kits. Should I experience resistance during my insertion, I will immediately stop my session. If during the session, I experience discomfort or pain, I am responsible for immediately stopping my session.                                                                     INITIALS __________________

I have reviewed and discussed with the Device Trained Therapist that I do not have any known contraindications or any health concerns. I wish to proceed with my colon hydrotherapy session(s).

Client Name _________________________________________ Signature __________________________________________  Date ______________
(For clients 18 or under, the signature & attendance of the parent or guardian for insertion is required.)

As a Trained Therapist,  I will always follow the FDA Device Manufacture use & maintenance guidelines. I have reviewed and discussed this form with the above client.  Therapist Signature ________________________________________________