Colonic Hydrotherapy Intake Form

All information will be held in strict confidence. This information may help your therapist to assist you better in your quest for optimal colon hydrotherapy results. It is not intended to diagnose or prescribe and is not a replacement for your regular medical attention by your physician.


Any problems with:
Have you taken in the past
Do you presently have or have you had in the last three (3) years any of the following conditions?

Liability Waiver

I declare that I am with full legal capacity and physical condition to receive Colon Hydrotherapy treatment and I do it with full knowledge and understanding that if I am not truthful I will be responsible for any risks implicated therein.
I hereby acknowledge and agree to receive therapies/treatments from Nirvana Natural Health Clinic with the understanding that the possible risks and/or injuries which I may sustain personally will be my full and complete responsibility.
Through this signing I release Nirvana Natural Health Clinic as well as all its employees and associates.

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