Intake and consent form - Reset by Mallory

Name *

First

Last

Date *

Address, City, State, Zip *

Cell Phone Number *

Email *

Height *

Weight (lbs) *

Birthdate *

Doctor's Name *

First

Last

Doctor's Telephone *

Have you been diagnosed with any of the following? *

If you answer yes to any of these, colon hydrotherapy is not for you

How often do you have a bowel movement? *

Are they... *

Spontaneous?
Only after eating?
Require straining?
Effortless?

Do you have hemmorhoids or other rectal problems? *

Yes
No

How often do you use a laxative, herbal laxative, and or stool softener? *

Have you ever had rectal bleeding, if yes, when? *

Do you consume... *

Sugar or salt cravings? *

Yes
No

Vegetarian/Vegan? *

Yes
No

Water intake per day? *

Exercise? (Type and frequency) *

Hours Sleeping? *

I, _________________, by signing this form am stating that I’ve provided truthful information to the best of my knowledge to the hydrotherapist. I consent to this treatment and remove Mallory Perry, the hydrotherapist, from any of all liability. *

By typing your name above you are signing this form