Medical Form - Colon Hydrotherapy Regular clients

Regular Client Forms

Medical Form - Colon Hydrotherapy *

All clients to complete before appointment

Name *

First

Last

Mobile Phone *

Date Of Birth *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Colon Hydrotherapy (Irrigation) Treatment / 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. *

Yes
No

I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if booked or recommended by Jade. *

Yes
No

Has there been any medical changes since your last appointment OR SINCE FILLING OUT YOUR ONLINE MEDICAL FORM? IF NONE, PLEASE WRITE NONE * *

Please check whether you have any of the following conditions for which this treatment is contraindicated: * *

Unmonitored High BP
Ulcerative Colitis
Gl haemorrhage / perf
Tested positive for Covid-19 in the past 6 months and have any lasting issues relating to this Any surgery in the last 6 months
Pregnant
Renal Insufficiency (Kidney do not function)
Colorectal Carcinoma
Crohns
Gastric band or Sleeve fitted in last 6 months
Diverticulitis
Tachycardia
None of the above apply
Heart Failure
Hernia (not Hiatus)
Uncontrolled diabetes
Receiving chemotherapy or have in the last 3-6 months
Hypertension
Intussusception (Bowel telescopes on itself)
Bowel Obstruction
Blood thinners
Active fissure
None Apply

I confirm that all information on this form and filled out forms online are correct, I also sign to confirm that none of the list of contradictions apply to me *

Book an appointment!

Call me at: 07361 237 564 or book online clicking the link below

Book Appointment

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.