Please give the following contact details, and tick your preferred method of contact.
Please answer the following as accurately as possible:
Are you seeing your Doctor at present?
Do you suffer from any of the following – please tick:
General Bowel Movements
How would you describe your bowel movements? Please tick where appropriate:
Do you suffer from any of the following? Please tick where appropriate:
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)
I consent to the data I have given to be used for the purposes of documenting and communication in regards to the treatment I am undertaking.
I understand the data and information on paper copies will be stored securely and any data stored on electronic devices will be password protected.
Only information to my treatment will be held and it will be stored for no longer than necessary
My data will not be passed to any third party without my consent.
I am happy to receive any information on promotions and/or newsletter
I consent to being contacted by
Please fill in the form below with your enquiry and a member of our team will be in touch. Alternatively call us on
07891 663 692
I understand that by submitting my details I give permission for you to contact me with information relevant to my enquiry, I have also read and understood your Terms & Conditions.
07891 663692 |
104 Hertingfordbury Road, Hertford, Herts, SG14 2AL |
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