Nourishing Journey: Colon Hydrotherapy

While our detoxification services are considered very safe and effective for most, there are some contraindications that you should be aware of. In many cases, these therapies may still provide benefit, and it is up to your licensed physician to prescribe the most appropriate treatment.

For this reason, along with your consent, we may require a prescription or signed referral from a licensed physician for anyone having a contraindication listed proceed with caution column. Contraindicated column services will not be provided.

RESTRICTED

You cannot have this service

PROCEED with CAUTION

Service requires doctor note*

Bowel Movement Questionnaire

1. I have read the list of contraindications for colon hydrotherapy and verify that my answers are true.

2. I understand that I may need a prescription/referral from a physician.

3. If I experience any new health problems or a worsening of existing health problems, I will contact my physician immediately.

4. I understand that it is my responsibility to inform the practitioners at Nourishing Journey of any changes in my health that may be related to the listed contraindications.

5. While the therapist is certified in colon hydrotherapy, I fully understand that colon hydrotherapy is not a licensed profession in the state of Maryland. I acknowledge that I am responsible for inserting the tube required for the session and that the therapist is not licensed to do this for me. If I would like assistance with the insertion, I will ask the therapist and I give permission to the therapist to be of assistance. I also understand that the therapist cannot be held liable in doing so.

Your Signature below indicates you have provided true and accurate information to the best of your knowledge.