Intake Form Client Intake Form Please complete this form prior to your first colonic session. All information is confidential and intended to ensure your comfort, safety, and personalized care.Personal InformationFull Name First Last Date of Birth MM slash DD slash YYYY Phone Number:Email Address Street Address City Province Postal Code Emergency ContactFull Name First Last Relationship:Phone Number:How Did You Hear About Us?How Instagram Facebook Google Referral Walk-in / Local Business Other Referral Name First Last OtherGoals & ExpectationsWhat brings you in for a colonic today?Have you ever had a colonic before? Yes No If yes, when was your last session?Medical HistoryPlease list any vitamins and medications you are currently taking:Lifestyle & DigestionHow often do you have a bowel movement? 1–2x/day Every other day <3x/week [ Irregular Do you experience any of the following? Gas Bloating Food sensitivities Fatigue Skin issues Brain fog How much water do you drink daily? # glassesDo you follow a specific diet? :(e.g., vegan, keto, etc.)Contraindications Checklist Uncontrolled hypertension Active infection/fever Severe anemia Recent heart attack Severe hemorrhoids Open rectal wounds None of the above Informed ConsentI understand that: Colon hydrotherapy is not a medical treatment. It is not intended to diagnose or treat medical conditions. I must inform the therapist of any new or worsening symptoms. I may stop the session at any time. Results may vary depending on individual health and lifestyle Client Name First Last Date MM slash DD slash YYYY
