Name
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First Name
Last Name
Email Address
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Mobile phone (include +Country Code)
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Country of birth
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Sex
Age
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Are you residing in Bali?
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Address in Bali
How did you hear about Aqua Health Spa
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Occupation
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Does your work affect your health?
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Is this your first colonic?
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Name and place of previous clinic?
List any digestive / laxative products you are currently taking
Do you take a Pro-Biotic supplement?
*
Note: We will always recommend one for you
Do you suffer from any food allergies or intolerances?
List any internal surgeries / medical procedures in last 3 years?
Please mark any of the following that may apply to you:
How often do you have a bowel movement?
Do you exercise regularly?
Please mark any of the following that are consumed or craved daily:
On scale of 1-10 what is your commitment to being healthy?
What is the main reason for your visit today?
CANCELLATION POLICY:
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Appointments must be cancelled or changed at least 24 hours in advance of your scheduled booking, otherwise you will be billed for the total cost of the services.
Disclaimer:
Colon Hydrotherapy is not intended to replace the relationship with your primary health care providers and your consultation with a Colon Hydrotherapist is not intended as medical advice. The therapist intends only to share their knowledge and information from their education, research, training, and experience. The Colon Hydrotherapist will encourage you to be open to new information on the effectiveness of colon hydrotherapy and the fundamental role of diet, exercise, supplementation, stress management and emotional or mental work. I agree to make my own health care decisions based upon my own research and in partnership with my primary health care provider, doctor or naturopath. The information and service provided is not used to prescribe, recommend, diagnose or treat a health problem or disease. It is not a substitute for medical care. I am aware that there are risks associated with colon hydrotherapy including, but not limited to perforation, injury, nausea and illness. I am solely responsible for the insertion of my rectal tube and for the flow of water. If I experience any resistance during insertion or any discomfort or pain during my treatment I will immediately stop my session. I am fully aware that Aqua Natural Health or its employees do not claim to cure or treat any condition or disease with Colon Hydrotherapy. Please schedule an appointment with our naturopath for more comprehensive advice.
CONTRAINDICATIONS:
A contraindication is a symptom or health history that makes it unsafe or inadvisable to have a particular therapy. Please check any box which may apply to you...(Written consent from your medical practitioner may deem you eligible for treatment).
By checking the box below, I confirm that I have read and understand the Aqua Natural Health contraindications policy and cancellation policy and am fully aware of all the disclaimer information.
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Name (as electronically signed)
*
First Name
Last Name
Todays Date DDMMYYYY
*
Thank you! We'll be seeing you very soon.
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Thank you! We'll be seeing you very soon.
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Thank you! We'll be seeing you very soon.
