Colonic Release Form

I, the undersigned, am in full agreement that Colonic irrigation is not a proven method, cure or treatment of any 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. The device being utilized in this facility is a fda-registered class 2 gravity device that can be used prior to endoscopic procedures. I understand I will insert

my own speculum and will be in full control of the procedure. 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 facility at the time I sign this waiver of consent and that at any time those laws can change and neither I, my family, nor my representatives will hold

the equipment manufacturer, facility or their employees responsible for my personal choice to receive colon irrigation at this facility or hold them liable for any changes or variation of

the law after the time of my dated signature below. All results of my session(s) are contributing to research and the utilization in future programs of self health aid while reserving my

privacy and waive any liability on behalf of the technician serving me.

Client Signature: 

Date:

If you are currently taking any medication for any condition, prescription or non you may want to check with your doctor before using colonic irrigation. If you have ever been diagnosed

with any intestinal condition or have taken any medication that can weaken the intestinal walls, you should check with your primary health care provider

before using colonic irrigation. If you are not sure of the side effects of the drugs you are using , you can check on the internet or with your local pharmacist or doctor.

I attest by my signature below that contraindications and adverse events have been fully explained and discussed with me.

Client Signature:                                                                                                                                                          

Date:

Provider Signature:                                                                                                                                                    

Date: