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Intake Form

COLON HYDROTHERAPY

BASIC INFORMATION

Birthday

MEDICAL INFORMATION

CHECK THE BOXES THAT CONCERN YOU

Multi choice
Multi choice

NUTRITION INFORMATION

Do you Fast?
Yes
No

Informed Consent Form

Love Your Gut Mint Hill, nor its associates do the following things, either implied or intended:


  1. We do not diagnose.

  2. We make no attempt to cure or treat any condition.

  3. We make no claims or imply any claims to cure or treat any condition.

  4. We do not claim that any supplemental material we may speak about will cure any condition, or that its purpose is to treat any condition.

  5. We do not prescribe or treat disease, however, we do attempt to educate you in/on foods and good diet and exercise if it is not contradictory to the recommendations of your primary health care provider or physician.


I, undersigned client, understand the above statements. I, as the client, understand that diet and nutrition is considered to be an inexact science and that the results obtained are not always constant or predictable.

Whether or not I participate in colon hydrotherapy is my decision, based on my rights of the ninth amendment. I must make all decisions relative to my well being and health. I further understand that Love Your Gut Mint Hill, is not a medical facility and none of its associates are attempting to portray themselves or conduct the activities of medical doctors. I also understand that the FDA registered equipment used in this procedure is intended for use in Colon Hydrotherapy. I further understand that I am in full control of

the colon cleanse I receive and I may choose to stop the device at anytime I want, at my own will.


I, undersigned, am in full agreement that colon hydrotherapy is not a proven method, cure or treatment of disease or condition nor has it been portrayed as such. Colon Hydrotherapy is a self-administered procedure

where I, as the user of the device, am solely responsible for my own actions and release the attending Technician, Facility, and Manufacturer from any liability regarding my health issues. The device being utilized in this facility is a gravity device, where I will self insert my own speculum and will be in full control of the procedure.

All results are contributive to research and the utilization in future programs of self health aid, while preserving my privacy, and waive any liability on behalf of the Technician serving me.


Colon Hydrotherapy is intended to irrigate the lower bowel. The colon is filled and emptied with filtered water either warm or cold. I understand that there may be benefits resulting from this procedure, however, I understand and agree that no warranties have been made as to the effectiveness or outcome of this procedure.


I understand that I will insert a tube/speculum into my rectum, and agree that I will witness that the tubing is sterile from a new container; the technician using sterile or new instruments.


Possible side effects of Colon Hydrotherapy include but are not limited to:

Multi choice

This list is not meant to be inclusive of all possible risks associated with colon hydrotherapy as there are both known and unknown side effects associated with any medication or procedure.


I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or

Court cost and reasonable legal fees, should this be required.


By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent for this colon hydrotherapy treatment and release the doctor, the person performing the colon hydrotherapy procedure and the facility from liability associated with this and all subsequent treatments with the above understood.

Date
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