Consultation Form - Colonic Hydrotherapy 

Name *
Name
Medical History
If you do not know your blood pressure reading please indicate if you suffer from any of the following (indicators of high blood pressure)
Nose Bleeds
Blurred Vision
Throbbing in Ears
Headaches,
Numbness or Tingling in hands/feet
Medical Conditions (that could mean we could not treat you)
Cancer of the rectum or bow *
Severe Haemorrhoids *
Anal Fissures *
Anal Fistula *
Recent Abdominal Cirrhosis *
Surgery (less than three months) *
Long term steroid use *
Gall Stones *
Severe Anaemia *
Diabetes *
History of congestive heart failure *
Insufficient / low renal function *
Are you pregnant or trying to be *
Other
Do you have any possible latex allergy? *
PLEASE READ AND CONFIRM
You confirm your understanding that i) colonic irrigation is part of an overall approach to diet and lifestyle and is not a medical treatment ii) we do not diagnose medical illness or any other physical or medical conditions iii) we do not prescribe medicines and iv) cancellations within 24hrs incur a 50% charge. *
You confirm you have informed us of any medical conditions, medications and past surgery, which could affect the treatment. *
You agree to advise us of any updates to the above, before any future treatment. *