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 truth 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. Sign and date