Colonic Prescription Form

Name*
Email*
Phone Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Sex
Marital Status*
Referred By*
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 informtion 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
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 6 months..
Abdominal Hernia: when a person has been diagnosed with abdominal hernia or has had surgery for abdominal hernia within the last 6 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 6 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 6 months.
Cardiac Condition: if a person has had cardiac surgery or has been diagnosed with a heart condition such as uncontrolled hypertension or 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 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 discharging from the rectum the person should obtain a doctor's release and use extreme caution when using colonic enemas.
Hemorrhoidectomy: after 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 person has been previously diagnosed by a Physician/Surgeon 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 or pregnancy. Colonic enema may be used if it is 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 enema is by my own personal choice and that the technician is not a medical doctor nor portrays tham 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 suce as perforation, injury, illness, and death have been alleged and claimed with the use of colon cleansing devices.