By signing your signature on our intake form, you are giving your consent and agreeing to all the following Terms and Conditions listed below.
Let it be known that NO employee of Colonbrook, NOR the owner, Cheryl Oakley, shall preform or attempt any of the following, either implied or intended as so declared below:
- We do NOT diagnose
- We do NOT prescribe or treat disease
- We do NOT attempt to cure any conditions
- We do NOT insert the disposable rectal nozzle
- We do NOT make claim or imply any suggestions are given to cure any conditions
- We do NOT claim that any supplement material we give or suggest wiII cure or treat any condition
- We DO attempt to educate you in the science of food and nutrition
You herby agree to the following:
By signature of our intake form, you are giving your consent to receive instruction on how to self-administer the colon irrigation equipment for use of your colon hydrotherapy session at Colonhrook as well as acknowledging my consent of the following:
I also agree that any type of therapy, adverse events are possible. Adverse events such as perforations, injury and, illness have been alleged and or claimed with the use of colon
irrigation/enema devices. I declare I have been completely honest in my statements pertaining to my health and in regards to any Contraindications which would prevent me from moving forward with my decision to proceed with this type of therapy. I understand that if I have any of the Contraindications now or have had any of them in the past, a colon hydrotherapy session could be a potential health risk and I would need to consult with and get approval from a medical doctor before I commence with this type of therapy. I also agree to immediately stop this procedure and inform the employee who is working with me if I feel nausea, experience any unusual discomfort, or pain. No personnel at this facility known as Colonbrook and or Cheryl Oakley, are attempting to neither portray nor conduct the activities of any medical doctor.
I, the undersigned consul tee, understand the above statement. I, as consul tee understand that diet and nutrition as well as colon cleansing is considered to be an inexact science and that the results obtained are not always constant or predictable. I also understand that there is no guarantee of any results. Whether or not I participate in this therapy is completely my decision. I have not been forced into having any therapy or treatment at this facility. I absolutely make all decisions essential regarding my personal health.
You herby notified and agree to the following:
If you are currently taking any medication" prescription, or non-prescription, for any condition, you should check with your physician before using any type of colonic irrigation equipment/enema apparatus. If you have been diagnosed with an intestinal condition or have taken any medication that may have weaken or caused damage to the intestinal walls, you should check with your primary health care provider before using any type of colonic irrigation equipment/enema apparatus.
If a Medical Doctor has diagnosed you with any of the Contraindications listed on the Colonbrook Intake Form, then you may not be able to proceed with this type of therapy. If you checked any box of diagnosed health condition listed on the Colonbrook Intake Form, you were asked to elebarate on your diagnosis and date your doctor diagnosed that/those condition in the box listed below the listed contraindications. If you checked both of the "NONE of the above" boxes, your responses are also taken in account as accurate.
Abdominal Surgery - *within 6 montrs
Acute Liver Failure
Anal Fissures or Fistulas - *abscess or boils
Cardiac Heart Condition
Colon Cancer - *or surgery
Hemorrhoidsctomy - * surgery
High Blood Pressure
Inflammatory Bowel Disease
Pregnant / *due date:
Recent Childbirth- *within 6 months
Renal Insufficiency or Dialysis
You herby agree to the following:
I declare by my signature that I have NO Contraindications or ANY Conditions, which would prevent me from moving forward with my decision to receive colon hydrotherapy at this time. I fully understand and agree that my visit and therapy is totally a voluntary decision. I have been extremely candid with all my answers and have filled out the Colonbrook Intake Form honestly.
I also understand that I am the only one legally responsible for my decision to move forward with this type of therapy. I have read all pages before me; have completely and I fully understand all of the questions contained out the Colonbrook Colon Hydrotherapy Intake Form.
I agree that Cheryl Oakley and or any other employee of this facility will not be held liable for any damages.
I realize that in order to secure an appointment I need to guarantee payment via my credit card. I absolutely understand that being on time for my session is vital. Should I fail to show up for my appointment, I understand that I will be charged a $40 "No-show" fee. I understand that after the initial set up session all future sessions will be at least 30 to 45 minutes. I further realize that my late arrival influences the session of others and for that reason alone I recognize that completion of my session is at risk and may consequently be forfeited as a direct result of my actions.
Appointments & Cancellations
I agree to give 24 hours Cancellation Notice for any appointment I'm unable to attend or need to reschedule. I also understand that without such notice my missed appointment is a lost of time for the business and, because of the reason, I will be charged a $40 fee before being allowed to utilize any future appointments and may be refused future services. I realize that if a charged of the $40 fee, it must paid before having any future service.
I understand that I am to use all sessions as describe by the Colonbrook Protocol, outlined below:
Week I - 2 colonic sessions should be completed in two parts, 24 to 48 hours apart. Week 2 - 2 colonic sessions should be completed in two parts, 24 to 48 hours apart; and any remaining sessions must be used at least once per week until completed.
I understand that all sessions are Pre-booked and Pre-Paid. This includes any and all Sessions, Packages, or Specials offered to me by Colonbrook. " My failure to follow protocol will result in the forfeiting of my remaining paid sessions.
I am in full agreement that
colon irrigation is not a proven method, cure or treatment of any disease or condition nor, has it been portrayed as such by Cheryl Oakley, any staff member at Colonbrook or the business itself. I understand that colon irrigation at this facility is a self-administered procedure where I, as the user of the device, is solely responsible for my own actions and release liability regarding any and all health issues that may arise after having colon irrigation at this facility.
I understand that I will self insert a disposable rectal nozzle and that I will be in full control of the procedure at all times. I am aware that not all states have laws governing the use of colon irrigation/enema devices. The facility I have chosen to visit is aware of the laws governing the use of such equipment at the time I sign this Waiver. I realize that at any point in time those laws could change. If such changes take place, neither my family or any representatives, nor I will hold Cheryl Oakley, Colonbrook nor any associates or equipment manufacturer responsible or liable for my personal choice to receive colon irrigation at this facility or hold them liable for any changes or variations of the law after the time of my dated signature below.