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CONTRANDICATIONS: Please check ✓ if any of the following apply to you:
ARE YOU PREGNANT?

FULL DISCLOSURE

I have not been diagnosed with any contraindication for colon hydrotherapy (see list above in bold). I, the undersigned, am in full agreement that colon cleansing is not a proven method, cure, or treatment of disease or condition, nor has it been portrayed as such.  Colon hydrotherapy 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 devices being used in this facility are FDA registered Class I enema devices, and I have not been diagnosed with any contraindication for colon irrigation. I am aware that these colon hydrotherapists are not physicians and are not licensed to insert, diagnose, or prescribe and therefore will not do so. I am aware that during the process of colon hydrotherapy, adverse events such as perforation, injury, and illness have been alleged and claimed with the use of colon hydrotherapy and enema devices. I hereby acknowledge that I am an active and willing participant in my colon hydrotherapy session.  I am aware that this facility’s devices require that I am responsible for self-insertion and results are not guaranteed. 

I FULLY UNDERSTAND AND ACCEPT ANY AND ALL LIABLITY IF THESE ARE NOT DISCLOSED IN WRITING AND PLACED IN MY FILE. I FURTHER RELEASE VIVO WELLNESS, STAFF AND ATTENDING TECHNICIANS FROM LIABLITY ASSOCIATED WITH THIS PROCEDURE AND FROM ALL HARM REGARDING THESE ISSUES AS STATED ABOVE. 

(For clients 18 or under, the signature and attendance of the parent or guardian for insertion is required)