Modern Colonics Confidential Client Form
Confidential Client Form
Sign in to Google to save your progress. Learn more
Full Name *
How did you hear about Modern Colonics? *
  The machine is fiberglass. There is a weight limit for the machine. Are you over 400lbs? *   *
FDA Approved Medical Device allows ONLY 18+ 
Date of Birth?   
 *
MM
/
DD
/
YYYY
  Marital Status   
Clear selection
Sex *
Address *
Preferred Phone Number *
Email *
Primary Care Physician
Emergency Contact Name and Phone Number *
Why are you interested in colonics? *
  *I CONFIRM THAT I HAVE NOT BEEN DIAGNOSED WITH ANY CONTRAINDICATIONS FOR COLON HYDROTHERAPY. Contraindication: Abdominal Surgery, Abdominal Hernia, Abnormal Bowel Distention, Acute Liver Failure, Anemia, Aneurysm, Cancer, Cardiac Condition, Crohn's Disease, Colitis, Kidney Disease, Anal Fissures/Fistulas, Diverticulitis, Hemorrhages, Hemorrhoidectomy, Intestinal Perforations, Rectal/Colon Surgery, Renal Insufficiencies, Diverticulitis 

INITIAL HERE:   
 *
If you are male type N/A. 

Are you or could you be pregnant? Colonics are NOT recommended during the first or third trimester without written consent from your OB/GYN. 

If yes, due date:  
 *
  Please list any medications/supplements you are currently taking and for what condition: Medication/Supplement:    *
  PLEASE READ and INITIAL: I am aware that this clinic uses FDA Registered Medical Devices for Colon Hydrotherapy and only uses disposable sterile nozzles or speculums. Although all therapists 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 clinic does not have a licensed medical director on site. No studies have been conducted for this alternative and complimentary modality. I am aware that adverse events such as perforation, injury, or 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 of the rectal nozzle, I will immediately stop my session. If during my session I experience discomfort or pain, I am responsible for immediately stopping my session. 
INITIALS:   
 *
I have reviewed the Client Confidential Form, that I do not have any known contraindications or health concerns. I wish to proceed with my colon hydrotherapy session(s). 
Name, Signature, and Date:  
 *
  Financial Policy at Modern Colonics: 
· We accept all credit cards, cash and check. · We offer packages with discounted fees. 
· Any appointment cancelled without 24 hour notice or no show will be charged the FULL PRICE of your appointment. 

SERVICES REFUND POLICY While we make every effort to make our customers as happy as possible, all service sales are final. We are a small business and unfortunately cannot offer refunds on any used or unused appointments/sessions for individual services, service packages or service series. 
· A credit card must be kept on file for any future cancellation appointments If you are sick or an emergency/unexpected event has occurred, a medical doctor’s note or receipt/excuse note is required to waive the charge within 30 days of the missed appointment. 

Name, Signature, and Date   
 *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms