New Client Intake Form

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1Client Information

2Health Information

3Colon Hydrotherapy Procedure

4General Information Disclosure

5Client Agreement

Name*

First Last

Date of Birth*

Phone*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

All clients must read, understand and sign this disclosure

Colon hydrotherapy services provided at Flora Integrated Wellness, LCC comly with section 2053.6 to business an professions code of the state of California. In compliance with this code you must be advised:

There are NO licensed physicians at this center and the individual performing colon hydrotherapy is ONLY a colon hydrotherapist; not a physician. This means we cannot and will not:

Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
Administer or prescribe X-Ray radiation to another person
Prescribe or administer legal drugs or controlled substances to another person
Cannot recommend the discontinuation of prescribed drugs or controlled substances prescribed by an appropriate licensed practitioner.
Cannot willfully diagnose or treat a physical or mental condition of any person under circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death.
Cannot set fractures
Treat lacerations or abrasions through electrotherapy.
Hold out, state, indicate, advertise, or imply to a client or prospective client that he or she is a physician or surgeon

Colon Hydrotherapy is an alternative or complementary to healing arts service lisenced by the state.

The services of Colon Hydrotherapy and the therapist that provide the service ARE NOT liscensed by the state

The session of Colon Hydrotherapy includes the following procedures:

The client will insert and retract the speculum
Warm temperature regulated and pressure controlled water will flow into the colon softening the fecal material which will be released through normal peristalsis into the sewer.
Your dignity and modesty will be maintained
The session will last approximately 30-45min

The theory of Colon Hydrotherapy is more historical and intuitive than scientific as there have not been any studies to validate the effectiveness of the modality. However, many cultures and societies believe that a clean colon can enhance the health of the individual. This started thousands of years ago with the simple enema and has evolved into the present day colonic. Many people report that they feel better after a colonic. On the other hand, there is a groing number of health care professionals that believe in the concept of auto intoxication, that sluggish bowel allows the body to reabsorb toxins from the colon. This theory may or may not have validity depending on who you listen to, but we know there is an increase level of toxins in our environment and common sense tells us that anything we can do to assist the body in riding itself should have some value.

Jodi Gilbert and Toby O'Dell has been trained by I-ACT guidelines and NCHT guidelines.

General Information Disclose Acknowledgement*

By signing this disclosure, you are acknowledging that you have read and understood the above text. You are also agreeing to abide by the disclosure and accept the consequences of any breach. You are aware of the risks and benefits of the disclosure and you are giving your informed consent voluntarily. You are not under any pressure or coercion to sign this disclosure. You have the right to withdraw your consent at any time without any negative consequences.

Refund Policy and Terms and Conditions*

Both the Client and ourselves have the right to terminate any Services Agreement for any reason, including the ending of services that are already underway. No refunds shall be offered, where a Service is deemed to have been completed or has begun and is, for all intents and purposes, underway. Any monies that have been paid to us which constitute payment in respect of the provision of unused Services, shall be refunded.

This refund policy is also included in our Terms and Agreements.

By signing below, you acknowledge your acceptance of this refund policy as well as the aforementioned Terms and Agreements.

Client information are confidential and written authorization is required to release any information.

We do not double book appointments

Please reschedule session if more than 15 minutes late

24 hour cancellation notice is required

You will be draped and at no time be exposed

You will have a consultation with your therapist to discuss the session

You may end the session at any time for any reason

Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement*

I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. By my electronic signature below, I agree to the massage policy and client agreement above.

Phone

This field is for validation purposes and should be left unchanged.

760-705-8387

Monday - Sunday 8am-7pm

All clients must read, understand and sign this disclosure

There are NO licensed physicians at this center and the individual performing colon hydrotherapy is ONLY a colon hydrotherapist; not a physician. This means we cannot and will not:

Colon Hydrotherapy is an alternative or complementary to healing arts service lisenced by the state.

The services of Colon Hydrotherapy and the therapist that provide the service ARE NOT liscensed by the state

The session of Colon Hydrotherapy includes the following procedures:

Jodi Gilbert and Toby O'Dell has been trained by I-ACT guidelines and NCHT guidelines.

Contact Us

Monday - Sunday 8am-7pm

760-705-8387

300 S. Escondido Blvd Suite 103 Escondido, CA 92025

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760-705-8387

Monday - Sunday 8am-7pm

New Client Intake Form

All clients must read, understand and sign this disclosure

There are NO licensed physicians at this center and the individual performing colon hydrotherapy is ONLY a colon hydrotherapist; not a physician. This means we cannot and will not:

Colon Hydrotherapy is an alternative or complementary to healing arts service lisenced by the state.

The services of Colon Hydrotherapy and the therapist that provide the service ARE NOT liscensed by the state

The session of Colon Hydrotherapy includes the following procedures:

Jodi Gilbert and Toby O'Dell has been trained by I-ACT guidelines and NCHT guidelines.

Contact Us

Monday - Sunday 8am-7pm

760-705-8387

300 S. Escondido Blvd Suite 103 Escondido, CA 92025

Sign Up for our Email

Menu

NEW CLIENT SPECIAL