Confidential Intake Form

Name *
Phone *
Date Of Birth *
Date Of Birth
Address *
Contraindictions *
These conditions may preclude your receiving Colon Hydrotherapy. Please check ALL that apply.
Do you experience *
Please check ALL that apply.
Bowel Movements *
Frequency (please check ALL that apply)
Occurance *
Use Of Laxatives *
WAIVER OF LIABILITY: I understand that the Therapist does not diagnose illness, disease, or any physical or mental disorder. As such, the Therapist does not prescribe medical treatment or pharmaceuticals. It has been made clear to me that colon hydrotherapy is not a substitute for medical examinations and/or diagnosis; and that it is recommended that I see a physician for any physical ailment that I may have. I have stated all my known medical limitations and do take it upon myself to keep the Colon Hydrotherapist updated on my physical health. In consideration of colon irrigation offered to me by Kenosha Colontherapy LLC / Gale Ulbert, I agree that I will not institute any suit or claim against Kenosha Colontherapy LLC/ Gale Ulbert, for any damages, loss or injury.
By clicking "submit" you agree that you have read and agree with the above waiver of liability.