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A Charming Wellness Spa near Houston, Texas
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Colonic Prescription Form
Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Sex
*
Male
Female
Marital Status
*
Single
Married
Divorced
Widowed
Domestic Partnership
Referred by:
*
Friend
Relative
Internet
Social Media
TV
Event
Advertisement
Other
Occupation
*
Reason for visit
*
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
If there are any other conditions, please explain here:
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
Thank you!