Colonic Consent Form
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We Will Give Them $5 Off There Next Service
Questions for the therapist to review:
A. Have you ever had Colon Hydrotherapy:
B. Are you currently menstruating:   
C. How many cups of water do you drink in a day?
D. Do your smoke?
E. Do you drink alcohol?
F. Do you drink coffee? 
Bowel Movements:
If yes quantity daily/monthly
If yes quantity daily/monthly
If yes quantity daily
Contraindication to Colon Hydrotherapy

1. Have you had abdominal or pelvic surgery in the past 6 months:


2. If pregnant, which trimester of pregnancy are you in: 

3. Have you been Diagnosed with Colon Cancer:  

4. Have you every had Colon surgery:  

5. Have you every had a piece of your colon removed:  

I have read and understood the above statements and agree to use the Ion Cleanse within the stated guidelines. I release the Ion Cleanse technician and Aroma Wellness Clinic and Spa from any responsibility associated with my health during or after the session.

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