Colon Hydrotherapy Information Form

Please complete the form below prior to your appointment. All information is kept strictly confidential. Thank you.

* required field

There are benefits and risks of receiving colon hydrotherapy. Many have reported favorable outcomes from colon hydrotherapy. Different results may vary. I agree that I am requesting this service on my own initiative and I acknowledge that the therapist and Main Street Spa & Wellness Center do not diagnose ailments or prescribe treatments. I release Main Street Spa & Wellness Center and their staff from liability for claims arising from the use of colon hydrotherapy services. We reserve the right to restrict or refuse any client.

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