How Did You Hear About Us? (Please Circle Below)

INTAKE FORM

FULL NAME______

ADDRESS______

CITY______POSTAL CODE______

PHONE: (HOME)______CELL______

EMAIL ADDRESS______

DATE OF BIRTH______MALE OR FEMALE______

OCCUPATION______

HOW DID YOU HEAR ABOUT US? (PLEASE CIRCLE BELOW)

Internet Newspaper Friends Advertisement

Other (please specify) ______

What symptoms or health concerns bring you to this appointment?

______

Page | 1 List current medications______

Have you had surgery, or any organ(s) removed? ______

Contraindications for colon therapy and other digestive disorders, please circle any that apply to you.

Pregnant IBS Crohn’s Diverticulitis Polyps Gallstones

Colon Cancer Surgery Hernia Intestinal perforation Heart failure

Hemorrhoids Colitis Tumors Cysts

List Nutritional Supplements ______

Any allergies (please specify) ______

Do you experience any of the following? (Please circle if it applies to you)

Bloating Constipation Gas Burping Diarrhea

Abdominal pain Headaches Back pain Fatigue

What is your blood type? ______

Do you use laxatives? What kind? How often?

LIFESTYLE

Do you smoke? Y N Water consumption daily______

Page | 2 Exercise? Y N if so how often______

FOOD Consumption daily Meat %______Vegetables%______

Fruit %______Grains/Bread %_____Junk food %______Dairy%______

BOWEL MOVEMENTS

How many bowel movements per day? ______

Do you have to strain to have a bowel movement? ______

Do you have rectal bleeding? ______

Have you ever had a Colonic before? ______

CONTRACT

Please read carefully

I, the undersigned, acknowledge that the personnel at Colonic Spa are not prescribing (Ordering for use of medicine) for me at any time, and I will not hold them accountable for such. They are not doctors or responsible for my health choices. Any recommendations I receive are not intended as primary therapy for any symptom of disease, but as means of enhancing the quality of my diet. Any medical problems or illnesses are to be diagnosed by my primary doctor, as Colonic Spa will not do such. I understand the therapist is helping me with natural hygiene at my own risk.

I understand Colonic Spa has a 24 hour cancellation policy. I understand, if I cancel my appointment without 24 hours notice, I will be charged $50.00.I

Page | 3 understand, If I do not show up to my appointment, I will be charged the full amount for my treatment. If I have a package, one treatment will be deducted.

FULL NAME: ______DATE: ______

SIGNATURE______

Page | 4