I consent to the treatment of Colon Irrigation and understand there may be side effects depending on my present health condition and that some cramping and discomfort including nausea may occur. Although extremely rare, and depending on your condition, bowel perforation can occur.
I take full responisbility and ownership for any undiagnosed illness, undiagnosed condition such as diverticulitis, weakness of the colon wall that could result in an adverse reaction.
Colon Hydrotherapy is NOT intended to replace the relationship with my primary health care providers. My consultation with a Colon Hydrotherapist is NOT intended as medical advice. I have not been diagnosed with any contraindicationed medical conditions for colon hydrotherapy (see above I am aware that any UNDIAGNOSED contraindicated condition for colon hydrotherapy could result in an adverse reaction. / am aware that Colon Hydrotherapists are NOT Physicians and therefore do not insert, diagnose or prescribe. I am aware that adverse events such as perforation, injury and illness have been alleged with the use of colon hydrotherapy. I am responsible for the insertion of my rectal tube. If I experience resistance during the insertion of my rectal tube or any discomfort/pain during my treatment I will immediately stop my session. I am aware Perth Colonics does not claim or treat any condition or disease. I have been made aware of the pre/post colonic protocol and I understand that not following protocols could cause adverse effects. I am aware that I have an ongoing responsibility on subsequent visits to advise of any changes to my medical condition or circumstances.
(For clients under 18, the signature and attendance of the parent or guardian for insertion is required.)