Colonic Consent Form
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Referred by a friend Great! What is there name?
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.

By clicking "I have read and understood", you agree to our Terms of Use, Privacy Policy and Disclaimer.

© 2018 by H2o Flo Colonics in Toronto.