Colon Hydrotherapy (Irrigation) / Data Consent Form

Data Consent Form

I confirm that I have provided, to the best of my knowledge & ability, the relevant information about my health & lifestyle. I agree to receive colon hydrotherapy from Jade & to inform my therapist of any relevant changes in my health & lifestyle. I have understood the treatment that I am consenting to & confirm that I have no reason to consult with my GP before undergoing the treatment. *

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Confirmed *

Signature (Please print name):

Declaration I agree to undergo a colon hydrotherapy treatment and to receive enema herbs or coffee if this is part of my treatment if recommended by my Therapist, Jade *

Yes
No

Colon Hydrotherapy is a safe and effectively cleanses your large intestine - colon. Your Therapist does not diagnose disease or prescribe medications. Should any of your responses to any of the above questions contraindicate Outwood Colon Care you will be advice to seek your doctors help. It is your responsibility to provide full and complete answers so your Therapist can treat you correctly. Also you must inform us of any changes in your health between treatments. General Data Protection Regulations (GDPR) The general data protection regulation (GDPR) replaces the Data Protection act from 25.5.2018. Any personal data used for the purposes of documentation and communication in regards to the treatment you have are going to undertake or have enquired about will be stored securely. It will only be used for specific information concerning Outwood Colon Care treatments and stored for no longer than necessary. It will not be passed on to any 3rd party without your consent. Data is held on electronic devices with be password protected, which will be stored securely. I consent to my data being used for the purpose of documentation and communication in regard to the treatment and services provided by Jade at Outwood Colon Care. *

I consent to the data I have given you to be used by Jade for the purposes of documenting and communication in regards to the treatment I am undertaking. *

Yes
No

I understand the data and information on paper copies will be stored securely in any data stored on electronic devices will be password protected. *

Yes
No

Only information to my treatment will be held and it will be sorted for no longer than necessary. *

Yes
No

My data will not be passed to us any third party without my consent. *

Yes
No

I am happy to receive any information on promotions and/ or newsletter *

Yes
No

I consent to being contacted by Email *

Yes
No

I consent to being contacted by Phone *

Yes
No

I consent to being contacted by Text *

Yes
No

I consent to being contacted by Facebook messenger *

Yes
No

Signed *

Print

Date *

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Any recommendations on this site are purchased and taken at your own risk. Jade Brown accepts no responsibility for any issues arising from any recommended product on this site.

You should always contact your GP if you have any questions prior to taking any supplements and supplements are never to be taken as an alternative to a healthy and balanced diet and lifestyle.

Please. note: Colonic Hydrotherapy is not in any way intended as a ‘cure’ or ‘medical’ treatment. It should not be seen as an alternative to seeing your GP if you have any health concerns. Neither is intended to infer or imply symptoms of IBS or other bowel conditions will be solved.