top of page

Colonics Client Intake Form

All information is confidential. You will be charged a $35 deposit upon submitting this form. Once received, I will reach out to you to set up your appointment. Thank you!

Birthday
Year
Month
Day
Do you have any of the following conditions? (Check all that apply)
How often do you have a bowel movement?
How would you describe your daily water intake?

DISCLAIMERI understand that Colon Hydrotherapy, also known as colonic irrigation, is a natural therapy intended to promote digestive health and detoxification. This procedure is not intended to diagnose, treat, cure, or prevent any disease. I acknowledge that Colon Hydrotherapy is not a substitute for medical care, and I should consult a licensed medical professional for any health concerns.


I understand that Colon Hydrotherapy involves the introduction of filtered temperature-controlled water into the colon to help remove waste. While generally safe, possible risks include dehydration, electrolyte imbalances, discomfort, cramping, or temporary changes in bowel habits. I acknowledge that I am responsible for informing my practitioner of any concerns or discomfort during the session.


I confirm that I have disclosed all relevant health conditions and medications that may affect my ability to receive Colon Hydrotherapy safely. I understand that I should not undergo Colon Hydrotherapy if I have any of the following conditions:

  • Active gastrointestinal infection

  • Severe hemorrhoids

  • Uncontrolled high blood pressure

  • Recent abdominal or rectal surgery

  • Pregnancy (especially in the first and third trimesters)

  • Cancer of the digestive tract

  • Severe anemia

  • Kidney or liver disease

  • Any other condition as advised by a medical professional.


By signing this waiver, I release The Dharma Den, its employees, and affiliates from any liability related to Colon Hydrotherapy. I acknowledge that I assume full responsibility for my health and well-being.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Year
Month
Day
Deposit
$35
bottom of page