Skip to content
Main Street Spa Online Reservations Are Currently Down Please Call for Reservations
804-644-1084
Home
About Us
Services
Contact Us
Specials
Home
About Us
Services
Contact Us
Specials
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Total Body Wellness
Wellness Services
Contact Us
Specials
X
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Wellness Services
Spa Packages
Contact Us
Specials
Gift Certificates
Client Form
Policies and Procedures
Events
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Wellness Services
Spa Packages
Contact Us
Specials
Gift Certificates
Client Form
Policies and Procedures
Events
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Wellness Services
Spa Packages
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Total Body Wellness
Wellness Services
Contact Us
Specials
Gift Certificates
Client Form
Policies and Procedures
Events
X
Gift Certificates
Client Form
Policies and Procedures
Events
Gift Certificates
Client Form
Policies and Procedures
Events
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Total Body Wellness
Wellness Services
Contact Us
Specials
X
COLON HYDROTHERAPY HEALTH FORM
Name
*
Birthdate
*
Phone
*
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
*
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre & Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Email
*
Please fill in all information below. All information is kept strictly confidential.
Do you now or have you ever had the following:CONTRAINDICATIONS FOR CURRENT CONDITIONS
Anal Fissure (acute, painful crack or tear)
*
YES
NO
YEAR DIAGNOSED
Anal Fistula (infected anal fissure)
*
YES
NO
YEAR DIAGNOSED
Aneurysm, Abdominal
*
YES
NO
YEAR DIAGNOSED
Bowel impaction or inntruction
*
YES
NO
YEAR DIAGNOSED
Crohn’s Disease
*
YES
NO
YEAR DIAGNOSED
Colon Cancer
*
YES
NO
YEAR DIAGNOSED
Colon, Rectal, or Abdominal Surgery
*
YES
NO
YEAR DIAGNOSED
(Less than 6 mos. Ago) Kind of surgery
Colostomy
*
YES
NO
YEAR DIAGNOSED
Diverticulitis (Episode less than 6 mos. Ago, you must be symptom free at time of colonic.)
*
YES
NO
YEAR DIAGNOSED
Dysentery
*
YES
NO
YEAR DIAGNOSED
Gastroenteritis (food poisoning)
*
YES
NO
YEAR DIAGNOSED
Hemorrhoids (now painful or bleeding)
*
YES
NO
YEAR DIAGNOSED
Hernia, Unrepaired (Abdominal/Inguinal)
*
YES
NO
YEAR DIAGNOSED
Kidney Dialysis
*
YES
NO
YEAR DIAGNOSED
months?
Pregnancy
*
YES
NO
YEAR DIAGNOSED
Rectal Bleeding
*
YES
NO
YEAR DIAGNOSED
Ulcerative Colitis
*
YES
NO
YEAR DIAGNOSED
OTHER HEALTH CONCERNS
Adhesions
*
YES
NO
YEAR DIAGNOSED
Allergies
*
YES
NO
YEAR DIAGNOSED
please list:
Anorexia
*
YES
NO
YEAR DIAGNOSED
Blood Pressure
*
YES
NO
YEAR DIAGNOSED
Blood Pressure
HIGH
LOW
Bulimia
*
YES
NO
YEAR DIAGNOSED
Cancer
*
YES
NO
Type
YEAR DIAGNOSED
Treatment
Candida
*
YES
NO
YEAR DIAGNOSED
Chronic Fatigue Syndrome
*
YES
NO
YEAR DIAGNOSED
Constipation
*
YES
NO
YEAR DIAGNOSED
Cystocele
*
YES
NO
YEAR DIAGNOSED
Diabete
*
YES
NO
YEAR DIAGNOSED
SELECT
Insulin
Oral Medications
Diarrhea
*
YES
NO
YEAR DIAGNOSED
For how long?
Edema/Swelling
*
YES
NO
YEAR DIAGNOSED
Where?
Fibromyalgia
*
YES
NO
YEAR DIAGNOSED
Gas/Bloating
*
YES
NO
YEAR DIAGNOSED
Anything not mentioned:
*
Submit