Colon hydrotherapy services offered by A BRAND NEW LEAF WELLNESS CENTER are considered complementary or alternative to healing arts services. The individuals providing the service have been trained in the administration of colon hydrotherapy but are not licensed or certified by the state as healing arts practitioners nor are they trained or supervised by licensed practitioners or physicians. Colon hydrotherapy is based on the theory that cleansing the digestive tract is detoxifying the body. A BRAND NEW LEAF WELLNESS CENTER is not a medical facility and does not provide medical treatment.

Please answer all questions below:

Colon hydrotherapy is not suitable for everyone.  If you have "checked" any of the above contraindications you will need a written medical release from your doctor to receive a colon hydrotherapy treatment. 

By signing this agreement, I recognize and acknowledge that:

This is not an exhaustive list of all potential risks associated with colon hydrotherapy.  As with any procedure, there are both known and unknown side effects. 

• Colon hydrotherapy is not intended to replace the relationship with a primary care physician, and that if I have one, I will notify my physician of my intention to have colon hydrotherapy.
• Colon hydrotherapy is intended to irrigate the lower bowel. The colon is filled and emptied with filtered warm water.  I understand that there may be benefits resulting from this procedure, however, I understand and agree that no warranties have been made as to the effectiveness or outcome of the procedure.
• I understand that I will insert a tube/speculum into my rectum, and agree that I will witness that the tubing is sterile from a new container/package.
• I am aware adverse events such as perforation; injury and illness have been alleged and claimed with the use of Colon Irrigation.  
• I understand and acknowledge that in selecting this program, I may experience certain symptoms that include, but are not limited to: Increased Energy, Nausea, Vomiting, Cramping, Light Headedness, Excessive Gas, Overheating, Temporary Diarrhea, Headaches, Temporary Increase in Body Odor, Joint or Body Aches, Water Overtemperature, Perforation of Rectum/Colon, Hemorrhoids: (which may be irritated, inflamed or bleed), Increased Appetite, Over Hydration: (when multiple colonic sessions are done during short period of time), Irritation / Inflammation / Allergic Reactions of the rectum due to lubricant. 
• Colon hydrotherapy is not intended for use in persons under the age of 18 years old or over the age of 75.
• Colon hydrotherapy is not intended to treat, cure, or prevent any disease.
• I have not been advised by my physician to avoid colon hydrotherapy.
• I am not pregnant.
• I have not been diagnosed by a physician with dementia or Alzheimer's.
• I do not have active colitis, Crohn’s disease, diverticulitis, hemorrhaging, or undergone colon or rectal surgery within the past 12 months.
• I have not been diagnosed by a physician for kidney disease, congestive heart failure, severe anemia, abdominal hernia, gastrointestinal cancer, cirrhosis of the liver, intestinal tumors, renal insufficiency, or any other condition that my physician advises me against colon hydrotherapy.
• I have not been under the care of a physician for any chronic condition within the last 12 months.
• I will notify the colon hydrotherapist of any acute condition prior to my session.
• I acknowledge that I am participating in this procedure at my own initiative and it has not been recommended to me by A BRAND NEW LEAF WELLNESS CENTER or its officers, agents, contractors, or employees as a remedy or treatment for any particular ailments. 
• It is my responsibility to communicate with the colon hydrotherapist regarding any discomfort I experience or potential adverse reaction.
• I am responsible for immediately stopping my session should I experience any discomfort or pain.
• I have been fully informed of the nature and risks of colon hydrotherapy.
• I have been made fully aware of what I need to do before and after the colon hydrotherapy session.
• I am not under the influence of any drugs or alcohol and will not be during my session.

I agree that the above information is accurate to the best of my knowledge. I give A BRAND NEW LEAF WELLNESS CENTER permission to provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do not have contraindications. I have reviewed the list of the contraindications for colon hydrotherapy, and I hereby agree that I am responsible for my health and the services received here.

I will not hold the colon hydrotherapist, A BRAND NEW LEAF WELLNESS CENTER, or any of its employees, agents, or associates, responsible for any injuries, damages, or claims that may arise from my receiving colon hydrotherapy.

As consideration for being permitted by A BRAND NEW LEAF WELLNESS CENTER to participate in its Colon Hydrotherapy Program, I  agree that I, my assignees, heirs, distributes, guardians, and legal representatives will not claim against, sue or attach the property of A BRAND NEW LEAF WELLNESS CENTER or any of its affiliated organizations for injury or damages resulting from the negligence or other acts, howsoever caused, by any employee, agent, or contractor of A BRAND NEW LEAF WELLNESS CENTER or any of its affiliated organizations as a result of my participation in A BRAND NEW LEAF WELLNESS CENTER'S Colon Hydrotherapy Program. 

I release A BRAND NEW LEAF WELLNESS CENTER and its affiliated organizations from all actions, claims, or demands that I, my assignees, heirs, distributes, guardians or legal representatives now have or may hereafter have for injury, death, or damage resulting from my participation in A BRAND NEW LEAF WELLNESS CENTER'S Colon Hydrotherapy Program.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND A BRAND NEW LEAF WELLNESS CENTER  AND ITS AFFILIATED ORGANIZATIONS,  AND SIGN IT OF MY OWN FREE WILL.

DISCLAIMER - Every therapy, service, and product described or presented at A BRAND NEW LEAF WELLNESS CENTER is not a cure for any disease, ailment, or health condition. No medical claims are expressed or implied, either directly or indirectly, regarding the therapies, products, or services presented herein. We do not diagnose, treat, or prescribe. We are not licensed massage therapists, and do not perform any abdominal massage during your colon hydrotherapy session.

Notice Designed to comply with the State of California Guidelines in The Business and Professions Code of the State of California: Section 2053.6

California state laws requires that you acknowledge receipt of the information provided in this form and that you sign it, keep a copy for yourself, and that we keep one for at least three years. Our method of service in "Colon Hydrotherapy" is alternative and complementary to healing arts that are licensed by the state of California. under sections 2053.5 and 2053.6 of California's Business and Professional Codes, we can offer you these services, subject to requirements and restrictions that are described fully on the following pages. The idea behind "Colon Hydrotherapy" is as follows:

Colon Hydrotherapy services provided at this center complies with Section 2053.6 to the Business and Professions Code of the State of California. In compliance with the Code, you must be advised:

A)  There are NO licensed physicians at this center and the individual performing colon hydrotherapy is only a Colon Hydrotherapist, they are not a physician. This means and implies that they cannot and will not:

1. Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
2. Administer or administer X-ray radiation to another person.
3. Prescribe or administer legend drugs or controlled substances to another person.
4. Recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner.
5. Willfully diagnose and treat a physical or mental condition of any person under circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death.
6. Set fractures.
7. Treat lacerations or abrasions through electrotherapy.
8. Hold out, state, indicate, advertise, or imply to a client or prospective client that he or she is a physician, a surgeon, or a physician and surgeon.

B)  Colon Hydrotherapy is alternative or complementary to healing arts services licensed by the state.

C)  The services of Colon Hydrotherapy and the Therapist that provide the services are not licensed by the state.

D)  The session of Colon Hydrotherapy includes the following procedures:

1.  The client will insert and retract the speculum.
2. Warm (temperature and pressure controlled) water will flow into the colon softening the fecal material, which will be released through normal peristalsis into the sewer.
3. Your dignity and modesty will be maintained at all times.
4. The session will last approximately 30-45 minutes.

E)  The theory of treatment upon which Colon Hydrotherapy is more historical and intuitive than scientific as there have not been any studies to validate the effectiveness of the modality. However, many cultures and societies believe that a clean colon can enhance the health of the individual. This started thousands of years ago with the simple enema and has evolved into the present day colonic. Many people simply report they feel better after a Colon Hydrotherapy treatment. On the other hand, there is a growing number of health care practitioners that believe in the concept of autointoxication, that a sluggish bowel (one that is not regular) allows the body to reabsorb toxins from the colon. This theory may or may not have validity depending on who you listen to, but we know there is increased level of toxins in our environment and common sense tell us that anything we can do to assist the body of ridding itself of toxins should have some value.

F)  Training and Education: All therapists working at A BRAND NEW LEAF WELLNESS CENTER have been trained and follow the I-ACT Standard Operating Procedures, Regulations and Guidelines for Colon Hydrotherapy.

I acknowledge that I have read the above disclosure and have been given a copy of this document. This information was provided to me in a language I can read and understand.

By booking my appointment, I agree to the following terms:

• All appointments require a deposit at the time of scheduling. (Prices are subject to change without notice)
• A  minimum 24-hour advance notice is required for cancellations or rescheduling.  Late cancellations or no-shows for non-prepaid appointments will incur a $50 fee, if canceled less than 24 hours before the appointment. 
• Prepaid no-show appointments will be counted as a used session unless canceled at least 24 hours in advance. Late cancellations will allow for one rescheduled appointment.  If the rescheduled appointment is also a no-show or canceled late, it will be counted as a used session.
• Arriving more than 15 minutes late will result in the service time reduced.  Alternatively, the appointment can be rescheduled. 
•  In the event I choose to terminate my session, regardless of the reason or the duration of time I have already spent on the unit, I will be subject to the full fee corresponding to a 30-45 minute session. 

This policy is in place to ensure that the professional time and resources allocated for the session are duly compensated for, thereby maintaining the fairness and sustainability of our service provision.

• All service sales are final.  NO refunds will be issued for late cancellations, missed appointments, or cancellations due to undisclosed health conditions on this form.

By signing this agreement, you confirm your consent to these terms.