Name *

First Name

Last Name

Nose Bleeds

Yes

No

Blurred Vision

Yes

No

Throbbing in Ears

Yes

No

Headaches,

Yes, typically in morning

Yes, not at a typical occurrence

No

Numbness or Tingling in hands/feet

Yes

No

Cancer of the rectum or bow *

Yes

No

Severe Haemorrhoids *

Yes

No

Anal Fissures *

Yes

No

Anal Fistula *

Yes

No

Recent Abdominal Cirrhosis *

Yes

No

Surgery (less than three months) *

Yes

No

Long term steroid use *

Yes

No

Gall Stones *

Yes

No

Severe Anaemia *

Yes

No

Diabetes *

Yes

No

History of congestive heart failure *

Yes

No

Insufficient / low renal function *

Yes

No

Are you pregnant or trying to be *

Yes

No

Do you have any possible latex allergy? *

Yes

No

You confirm your understanding that i) colonic irrigation is part of an overall approach to diet and lifestyle and is not a medical treatment ii) we do not diagnose medical illness or any other physical or medical conditions iii) we do not prescribe medicines and iv) cancellations within 24hrs incur a 50% charge. *

Yes

No

You confirm you have informed us of any medical conditions, medications and past surgery, which could affect the treatment. *

Yes

No

You agree to advise us of any updates to the above, before any future treatment. *

Yes

No

Please advise if you would like to join our mailing list for newsletters and updates

You can unsubscribe at any time and we will never pass your details on to anyone else

Yes

No