Client Questionnaire


General Bowel Movements


I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if recommended by my Therapist

Colon Hydrotherapy is a safe and effectively cleanses your large intestine –colon. Your Therapist does not diagnose disease or prescribe medications. Should any of your responses to any of the above questions contraindicate colon hydrotherapy you will be advised to seek your doctor’s help. It is responsibility to provide full and complete answers so your Therapist can treat you correctly. Also you must inform us of any changes to your health between treatments.

General Data Protection Regulations (GDPR)

1. I consent to the data I have given to be used by Aqua-Tox for the purposes of documenting and communication
in regards to the treatment I am undertaking.
2. I understand the data and information on paper copies will be stored securely and any data stored on electronic
devices will be password protected.
3. Only information to my treatment will be held and it will be stored for no longer than necessary.
4. My data will not be passed to any third party without my consent.
5. I am happy to receive any information on promotions and/or newsletter.
6. I consent to being contacted by