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Please be advised all new clients are required to complete and submit the New Client Intake form after booking their initial service.

Note: New clients will not be permitted service without submission of this form.

NEW CLIENT INTAKE FORM

Please fill out the following form
in order for us to provide your booked services.

First Name

Last Name

Email

Phone

Address

Date of Birth

Age

Check all symptoms that applies

Constipation

Fatigue

Bad breath

Extreme stress

Bladder infection

Burning stomach sensation

Burning or itching anus

Have you you ever had colon hyroyherapy before?

No

Yes

Check all symptoms that applies

Abdominal Hernia

Abdominal Surgery within 6 months

Acute Liver Failure

Aneurysms

Anal Abscess or Boils

Heart Condition

Crohn's Disease

Colon Surgery

Colon Cancer

None of the above

Height

Weight

Martial Status

Check all symptoms that applies

Constipation

Fatigue

Bad breath

Extreme stress

Bladder infection

Burning stomach sensation

Burning or itching anus

Are you suffering from a medical condition, illness, or injury?

No

Yes

Check all symptoms that applies

Diverticulitis

Hemorrhoidectomy (surgery)

Inflammatory Bowel Disease

Intestinal Perforations

Currently Pregnant

Childbirth within 6 months

Rectal Bleeding

Renal Insufficiency or Dialysis

Ulcerative Colitis

None of the above

If you checked any of the specified conditions above, please elaborate on which conditions and dates of diagnosis. If you answered none of the above, please retype "none of the above".

I declare that the information I’ve provided is accurate & complete.

I have read and agree to the Colonbrook Client Agreement.Client Agreement

I have read and agree to the Colonbrook Consent Agreement.Consent Agreement

I have read and agree to the Colonbrook Waiver Agreement.Waiver Terms

I have read and agree to the Colonbrook Policy Terms.Policy Terms

I hereby on this date of sumission and all furture dates of service, delcare by my signature below that I have read and agree to all Colonbrook Colon Hydrotherapy Agreements, Terms, Conditions, Policies, and Waiver electronically provided to me within the Intake Form on colonbrook.com.

Your Signature

Thanks for submitting!

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