Colonic Prescription Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Please check all symptoms which you now have or have had in the past 6 months. Be as thorough as possible. Your health information is confidential. *

Abdominal Distention

Belching or Gas

Bloody Stools

Colon Trouble

Constipation

Diarrhea

Difficult Digestion

Excessive Hunger

Gall Bladder

Hemorrhoids

Hernia

Intestinal Worms

Jaundice Piles

Poor Appetite

Rectal Bleeding

None of the Above

Please indicate all of the following conditions you have or have had. *

Heart Problems

Hepatitis

Hernia

Herpes

HIV

Kidney Problems

Liver Problems

Lupus

Mononucleosis

Thyroid Problems

Venereal Infection

None of the Above

Acknowledgement

The following is a list of contraindications for using this procedure with caution or not using this procedure at all if you have ever been diagnosed with ANY of these conditions within six months. Abdominal Hernia: when a person has been diagnosed with an abdominal hernia or has had surgery for an abdominal hernia within the last six months. Abdominal Surgery: after recent abdominal surgery, since the administering of this procedure initiates peristalsis and the use of the abdominal muscles may aggravate sutures and the healing of the incision. A minimum of 6 weeks should pass after surgery before using colonic enemas unless prescribed by a doctor. Abnormal Distension/Masses: if a person has been diagnosed with abnormal colon distention or masses within the last six months. Acute Liver Failure: when a person has been diagnosed with acute liver failure. Carcinoma: when a person has been diagnosed with Carcinoma of the colon within the last six months. Cardiac Condition: if a person has had cardiac surgery or has been diagnosed with a heart condition such as uncontrolled hypertension, congestive heart failure, or any other heart conditions, colonic enemas are contraindicated without a doctor's release. Chrohns Disease: if a person has been diagnosed with Chrohns Disease, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Colitis: if a person has been diagnosed with Colitis, ulcerative colitis, etc., the person should obtain a doctor's release and use extreme caution when using colonic enemas. Dialysis Patients: when a person is restricted on fluid intake, a doctor's release should be obtained, and colonic is done according to doctor's order. The doctor should give specific details of fluid intake. Diverticulosis: if a person has been diagnosed with Diverticulosis/Diverticulitis, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Fissures/Fistulas: when a person has been diagnosed with fissures/fistulas, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Hemorrhaging: when a person has a flow of bright red blood discharge from the rectum, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Hemorrhoidectomy: after the removal of hemorrhoids, a doctor's release should be obtained, and the procedure must be administered with caution, as hemorrhoids could return even without colonic enemas. Intestinal Perforations: when a Physician/Surgeon has previously diagnosed a person to have or have had intestinal perforations, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Pregnancy: colonic enemas are contraindicated during the FIRST and LAST trimesters of pregnancy. A colonic enema may be used if it is a general procedure to administer an enema prior to childbirth. The colonic enema would just be substituted for the traditional enema, affording the person more privacy and comfort. A doctor's release should be obtained. Rectal Surgery: after recent rectal surgery, the person should obtain a doctor's release and use extreme caution when using colonic enemas. Renal Insufficiencies: when a person has been diagnosed to be renal insufficient, the person should obtain a doctor's release and use extreme caution when using colonic enemas. If a Physician or Surgeon has ever diagnosed you with any intestinal conditions or if you have been on any medication, which may weaken the intestinal walls, you should obtain a doctor's release and use extreme caution when using colonic. If you are currently taking medication for ANY condition diagnosed by a Physician or Surgeon, you should check with your Doctor before electing this procedure to ensure the medication will not be interfered with by the additional water intake and absorption. By submitting this form, I agree that I have read the above contraindications for colon cleansing, and by submitting this form below, I testify that I DO NOT have ANY of the above conditions. I am also aware that the use of colon cleansing enemas is by my own personal choice and that the technician is not a medical doctor nor portrays them as such. Colon cleansing has not been clinically tested to provide ANY medical benefits. This procedure is used solely for the purpose of evacuating the lower bowel. I am aware that adverse events such as perforation, injury, illness, and death have been alleged and claimed with the use of colon-cleansing devices.

Agree

Do Not Agree