Phone: (905) 919-9799
Fax:     (647) 956-0627
Email:  info@kleenkolonics.com

Kleen Kolonics

Colon Hydrotherapy with a difference

Kleen Kolonics Intake Form

To save time, please complete this form when you come in for your colonic

Colon Hydrotherapy Intake Form



Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­________________________________________________________Today’s Date______________


Address:________________________________________________________________________________


City:_________________________ Province:_______________ Postal Code:_______________________


Phone:_____________________ Email:_______________________________________________________


May we contact you at the above email with upcoming promotions, etc? Y/ N


Date of Birth:__________________________Age:__________ Sex (Please Circle) M   F


Height:______________Weight:_____________ Do you have any children?(Circle) Y   N


Number of Children:______ Are you pregnant right now? Y/ N


Ever Had A Colonic Before Y/ N When?_________________Where?______________________________


How did you learn of our services?___________________________________________________________


Major Physical Complaints_________________________________________________________________


List All Surgeries & Dates__________________________________________________________________


List all prescription medications you are presently taking_______________________________________­­­­___

_______________________________________________________________________________________


List all vitamins and/or herbal supplements you are presently taking_________________________________

_______________________________________________________________________________________


Do you drink caffeine Y/N How much caffeine daily?_____________


Do you smoke? Y / N (Circle) Cigarettes/Cigar/Other____________________________________________


List all known allergies or sensitivities:________________________________________________________


How many bowel movements do you usually have per day?_________________


Do you take laxatives? Y / N

  • Herbal Laxatives Brand:_________________________________________
  • Suppositories Brand:_________________________________________
  • Stool Softeners Brand:_________________________________________


I have chosen to have colon hydrotherapy because (circle all that apply): Doctor Referral/ 9th Amendment Right to Self Prescribe/ Other (Explain):______________________________________________________

_______________________________________________________________________________________


In case of emergency call_________________________________Phone:____________________________


I understand that all information shared in this visit is confidential and for educational purposes only and that it is not intended to replace your general medical practitioner.

Client Signature: ________________________________________________Date:_____________________


By initialing, I certify I am not presently diagnosed with the following contraindications_____________ (initial here)

Severe Hemorrhoids Abdominal Hernia Fissures Fistulas

Heart Disease Kidney Disease Perforations Cirrhosis

Rectal/Colon Surgery Colon Cancer G.I. Hemorrhage Aneurysm

Renal Insufficiency Severe Anemia Chron’s Disease Ilecolitis

Congestive Heart Disease Hypertension Rectal Cancer, SIBO or other rectal problems.


If you have experienced any of the above contraindications, list which ones and how long ago you experienced them:___________________________________________

______________________________________________________________________________________________________________________________________________________________________________

I understand that I am having Colon Hydrotherapy at my own risk and that Kleen Kolonics its owners, agents, management and employees assume no liability of any kind. I have been truthful in answering all the above statements, and am solely responsible for such.

Disclaimer
A Certified Colon Therapist is not a medical doctor and does not perform any medical diagnosis or treatment procedures. The services provided by a certified colon hydrotherapist are at all times restricted to consultation on the subject of nutritional matters or the sensitivities to various substances. Recommendation for other therapies (if any) are done for informative purposes only and does not involve diagnosing, curing, prognosticating, treatment or prescribing of remedies for the treatment of disease or any act, which will constitute the practice of medicine in this province for which a license is required. All suggestions (if any) regarding herbs or nutritional matters are based on historical and traditional use


Signature:___________________________________________________Date:________________________


CD1-02-No1-Kempff1951-Track02
Kempff, 1951 (Piano Sonatas)
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