PERSONAL HISTORY FORM

INFINITY HEALTH & WELLNESS CENTER COLON HYDROTHERAPY 

INTAKE FORMS

Please fill out the following form to help us understand your physical condition.

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*The device being utilized in this facility is a FDA Registered Class I or Class 11 gravity device that can be used prior to endoscopic procedures. 

I am aware that not all states have laws governing the use of colon irrigation/enema devices. At the time I sign this waiver of consent and that at anytime thereafter those laws can change and neither, I, my family, nor my representative(s) will hold the equipment manufacturer, facility or their employees responsible for my personal choice to receive colon irrigation at this facility nor hold them liable for any changes or variations of the law after the time of my dated signature below. All results of my session(s) are contributive to research and the utilization in future programs of Self Health Aid, while preserving my privacy, and waive any liability on behalf of the technician serving me. 

*Contraindications: Have you ever been diagnosed with any of the following:

If any of the before mentioned contraindications apply, I should NOT have colon hydrotherapy services without a doctors permission. By signing this form and accepting service, I assume responsibility and waive any and all claims against Infinity Health & Wellness Center, LLC, it's owners and other colon hydrotherapists associated with this facility, and the equipment/product manufacturer, suppliers. 

I am aware that adverse events such as perforation, injury and illness have been alleged and claimed with the use of colon irrigation and enema device use. I understand I will self-insert my own speculum and will be in full control of the procedure. If during my self-insertion of the sterile rectal tube there is any resistance or if I experience discomfort or pain, I am responsible for stopping my session and immediately notifying the therapist. I limit the right to seek relief for negligence or any other civil remedy against a person/facility providing services subject to the requirements of this section. 

If I request colon hydrotherapy and other holistic health and wellness coaching - related services, I understand that Infinity Health & Wellness Center, LLC does not claim to treat any disease or condition and that services are not intended as a substitute for regular medical care.

 

I, the undersigned, am in full agreement that colon irrigation is not a proven method, cure, or treatment of disease or condition, nor has it been portrayed as such. Colon irrigation in this facility is a self-administered procedure where I, as the user of the device, am solely responsible for my own actions and release liability regarding my health issues. 

Thanks for submitting!

www.infinityhealthwellness.com 

3502 Scotts Lane, Phila, Pa 19129 I 267-338-9455