Colon Therapy Consent Form

Section 1: Basic Information

Date

How did you hear about us?

Is this form being filled out for a minor (under 18)?

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First Name

Last Name

Preferred Name / Nickname

Date of Birth

/ /

Gender at Birth

Preferred language (optional)

Race (optional)

Ethnicity (optional)

Soc. Number

Referred By

Mobile Phone

Address 1

Address 2

City

State

Zip Code

Emergency Contact Name

Emergency Contact Phone

Which location are you visiting?

Is this your first visit to a Be Well Center?

Insurance Info (If Applicable)

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Are You Self Insured or through another Individual?

If Insured through another Individual, Please enter the Following Information:

First Name

Last Name

Sex

Relationship to Patient

Date of Birth

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Address

Phone Number

Medical History

Primary reason for seeking colon hydrotherapy

Current digestive symptoms

How often do you have bowel movements?

Do you use laxatives?

Date of last colonoscopy (if applicable)

Please list any medications or over-the-counter medications you are taking and for what ailment(s)

If You are pregnant please state due date

Is there a history of colon cancer in your family

Any other considerations we should be aware of?

Have you experienced Colon Hydrotherapy before?

Do you participate in any other forms of alternative healing?

Do you drink alcohol or take recreational drugs? If Yes please list

Are you on a special diet?

FULL DISCLOSURE

I UNDERSTAND AND FULLY DISCLOSE ANY AND ALL MEDICAL TREATMENTS THAT I HAVE HAD IN THE PAST ONE-(5) YEARS THAT MAY DIRECTLY OR INDIRECTLY BE RELATED TO ME PARTICIPATING IN THE USE OF COLON HYDROTHERAPY. THIS MAY INCLUDE BUT IS NOT LIMITED TO GASTROINTESTINAL EVALUATIONS, DIAGNOSIS, PROCEDURES, MEDICATIONS, SURGERIES AND THE LIKE. ALSO, BUT NOT LIMITED TO ANY PROCTOLOGY DIAGNOSIS, EVALUATIONS, PROCEDURES, MEDICATIONS AND SURGERIES. BY SIGNING THIS FORM, I AM DISCLOSING THAT I HAVE NOT HAD ANY UNDISCLOSED GASTROINTESTINAL PROCEDURES SUCH AS; BUT NOT LIMITED TO EGD (ESOPHAGEAL STOMACH SCOPE), COLONOSCOPY, SIGMOIDOSCOPY, ANAL SCOPE AND THE LIKE. I HEARBY CONSENT TO THE SERVICES THAT WILL BE PROVIDED AS WELL AS MY OWN PHYSICAL LIMITATIONS AND I AGREE TO ASSUME THE RISK OF ACCEPTING THIS SERVICE. I ACKNOWLEDGE IF I HAVE ANY MEDICAL CONDITIONS THAT MAY BE AFFECTED BY THE SERVICE REQUESTED, I WILL ADVISE AND DISCUSS SUCH CONDITIONS WITH THE SERVICE PROVIDER. I AM AWARE THAT IT IS ALWAYS ADVISABLE TO CONSULT A PHYSICIAN BEFORE UNDERTAKING ANY SUCH SERVICE.

I HAVE NOT BEEN DIAGNOSED WITH ANY CONTRAINDICTIONS FOR COLON HYDROTHERAPY. I AM AWARE THAT COLON HYDROTHERAPISTS ARE NOT PHYSCIANS AND THEREFORE DO NOT INSERT, DIAGNOSE OR PRESCRIBE. I AM AWARE THAT ADVERSE EVENTS SUCH AS PERFORATION, INJURY AND ILLNESS HAVE BEEN ALLEGED AND CLAIMED WITH THE USE OF COLON HYDROTHERAPY AND ENEMA DEVICES. I AM RESPONSIBLE FOR MY OWN SELFINSERTION. IF I EXPERIENCE RESISTANCE DURING THE INSERTION, I WILL IMMEDIATELY STOP MY SESSION. IF DURING THE SESSION I EXPERIENCE DISCOMFORT OR PAIN, I AM RESPONSIBLE FOR IMMEDIATELY STOPPING MY SESSION. I AM AWARE THIS FACILITY DOES NOT CLAIM TO CURE OR TREAT ANY CONDITION OR DISEASE

I FULLY UNDERSTAND AND ACCEPT ANY AND ALL LIABILITY IF THESE ARE NOT DISCLOSED IN WRITING AND PLACED IN MY FILE. I FURTHER RELEASE THIS FACILITY FROM ALL HARM REGARDING THESE ISSUES AS STATED ABOVE.

Full Legal Name (This acts as your electronic signature)

I agree that by typing my name above, I am electronically signing this form. I understand that my electronic signature is legally binding and has the same legal effect as a handwritten signature, pursuant to the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN) and applicable state laws.

Yes, text and email me when appointments open up and about Be Well specials (optional). I agree to receive recurring automated marketing texts and emails from Be Well LifeStyle Centers at the number and email provided. Message frequency varies. Consent is not a condition of purchase or of receiving care. Message and data rates may apply. Reply STOP to opt out, HELP for help.

Please complete all sections of this form.