ADDRESS

4010 Dupont Circle Suite 518
Louisville, KY 40207

PHONE

502-893-2006

New Clients Form

Holistic Questioner

CONFIDENTIALITY-  Any information exchanged on this form, or during a session, is strictly confidential. It will be used for the sole purposes of providing the best health care services possible. Please complete ALL questions. 
Name:*
Phone:*
-
E-mail:*
Address:
DATE OF BIRTH:
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WEIGHT:
OCCUPATION:
EVER HAD A COLON HYDROTHERAPY BEFORE?
IF SO'WHEN?
HOW DID YOU LEARN OF OUR SERVICES? (If you were referred by one of our existing client, please mention their name so that we can THANK THEM with a discount on their next session as part of our Reward program)
ARE YOU NOW UINDER A DOCTOR'S CARE?
IF SO PLEASE EXPLAIN:
MAJOR PHISICAL COMPLAINTS:
LIST ALL MEDICATIONS & SUPPLEMENTS YOU NOW TAKE REGULARLY (INCLUDING OVER’ THE COUNTER)
LIST ALL KNOWN ALLERGIES:
HOW MANY BOWEL MOVEMENTS PER DAY DO YOU USUALLY HAVE? *
DO YOU HAVE TO STRAIN TO HAVE A BOWEL MOVEMENT?
DO YOU USE A STOOL SOFTENER OR LAXATIVE?
HERBAL LAXATIVE?
DO YOU HAVE HEMMORHOIDS OR OTHER RECTAL PROBLEMS?
HAVE YOU EVER HAD A BARIUM ENEMA?
IF SO, WHEN?
WHAT WOULD YOU LIKE TO RECETVE FR.OM THIS APPOINTMENT?
SIGNATURE:
Date:
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CHECK (“C”) FOR CURRENT CONDITION CHECK (“P”) FOR PAST CONDITION


INTELCTUAL CENTER
GROUNDING CENTER
MISCELLANEOUS
WORLD CENTER
I (Full name) *

hereby request and consent to the performance of colon hydrotherapy and other related procedure on me (or on the person named below, for whom I am legally responsible) by the colon hydrotherapist indicated below and/or other colon hydrotherapists who now or in the future treat me while employed by, working or associated with or serving as back-up for the colon hydrotherapist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that the attending therapist is not an allopathic doctor, but has been trained as a certified colon hydrotherapist. I fully understand that the attending therapist cannot diagnose, or prescribe and does not offer allopathic drugs, surgery, or chemical stimulants, or radiation therapy. I understand that illness is not being diagnosed, nor treated, or cured and no representation of such is being expressed or implied.

I understand that methods of treatment may include, but not limited to, the use of a colon hydrotherapy machine to put water into and out of my colon and to remove whatever is in my colon. I understand it is my responsibility to communicate with my therapist during the session.

I have been informed that colon hydrotherapy is a generally safe procedure. I do not expect the staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the staff to exercise judgment during the course of the procedure which the staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.

I understand that the following are possible contraindications, but not limited to:

  • Fissures/fistulas
  • Aneurysm
  • Rectal colon and /or rectal surgery
  • Abdominal hernia
  • GI hemorrhage/perforation
  • Advanced Crohn’s disease/ ileitis
  • Pregnancy (1st or 3rd trimester, unless Rx from physician)
  • Sever hemorrhoids
  • Renal disease
  • Cirrhosis of the liver
  • Uncontrolled hypertension
  • Sever cardiac disease

ANY OF TH ECONDITIONS LISTED ABOVE require a physician’s prescription as Colon Hydrotherapy is not performed without specific written medical guidance.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent, have been told about colon hydrotherapy and procedures, and I have had an opportunity to ask questions. I intend this consent form to cover the entire course of procedures and for any future procedures I receive.         

I have solicited the attending therapist’s services in good faith, exercising my free will and following the dictates of my own conscience which allows me to select what therapies I choose for my health.

I hereby release the colon hydrotherapist to assist me with my colon hydrotherapy session(s). In addition, I further release Hamri’s Health & Wellness, LLC, the owner(s), and their employees of any liability associated with therapies that I have solicited while at Hamri’s Health & Wellness, LLC.

(INITIAL) Cancellation Policy: I understand appointments cancelled in less than 48 hours’ notice is subject to cancellation fee. Missed or cancelled appointments in less than 48 hours are billed at the regular rate of the service(s) booked.

Electronic Signature:*
Date :*