Intake Form

How did you hear about Lavage? *

Name *

Address *

City *

State *

Zip Code *

Phone *

Email *

Occupation

Birthdate mm/dd/yy *

Emergency Contact *

What is your typical diet? Include Breakfast, Lunch, and Dinner.

How many bowel movements do you have per day? Or in a typical week? *

Do you have any allegeries? (Latex, peppermint, almonds, sesame?) *

Have you had a colonic irrigation before? *

If yes, when and where did you have a colonic irrigation?

Please tell us why you are coming to see us today along with any goals you may have? *

I agree and understand that any service and or information given by Lavage and or it's agents does not constitute medical practice or advice. Nor is it intended to replace the necessity of consultation with a physician. I understand that Lavage consultants are not licensed to diagnose illness, disease, or any other phyisical and mental disorder. Please sign using initial. *

I understand and agree the Lavage consultants do not provide any medical treatments nor do they prescribe medical treatments or pharmaceuticals. However, I understand that during the course of my treatment at Lavage, natural remedies such as herbs and othr natural supplements may be recommended to me by my therapist. However, I understand and agree that these recommendation are completely discretionary and are not intended as a substitute for consulting a physician/other health care professionals or to treat an existing illness. Please sign using initial. *

I further agree that lavage will incur no legal or moral liabilities to you or anyone else for the services and or advice provided to you by Lavage and or it's agents. Please sign using Initial. *

I certify that I am requesting the services and information provided by Lavage and it's consultants, and take full responsibility for engaging in any and all services as well as following any and all suggestions Lavage and it's consultants provide. Please sign using Initial. *

Type full name as consent for signature. *

Today's Date *

If you are unable to make your appointment we ask that you contact us, via email, text, or call us. Let us know 24 hours in advance prior to your scheduled appointment. We thank you for your courtesy.

Intake Form

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