Please review the conditions below. These items listed below are contraindications for Colon Hydrotherapy. If any of these apply to you, we will likely not provide or suggest colonics to you unless we have a written prescription or referral from a physician. Please check all that apply at this time and in the past. Our programs do not require the use of Colon Hydrotherapy to be effective however it may be a recommended option for certain individuals. Always check with your physician before starting any new health regimen or making a lifestyle change.

The items below are NOT contraindications, however please check if any of these apply to you.

To help us understand what is most important to you about your health, please indicate which of these areas are of concern to you at this time.

Please rate the severity of the following symptoms/health concerns that currently apply to you on a scale of 0 to 5, with "0" showing no symptoms, no concern or not applicable and "5" being problematic or very concerned.

Some say you are what you eat. Please share candidly, there is no judgment here.

I, the undersigned, understand that Sacred Waters is not a medical facility and does not employ medical providers. The services I receive at Sacred Waters Wellness Arts Studio may be non-traditional or unconventional and are not for the purpose of treating disease or for replacement of medical needs. Such services are commonly referred to as complementary, integrative or alternative health services. Because many efforts may be necessary to resolve underlying difficulties in the body’s capacity to function, they are also known as “functional” techniques. These services may or may not be recognized as standard healthcare practices and may be considered investigative or experimental. If there is something that I do not understand, I will ask questions prior to submitting this form and/or proceeding with using services from Sacred Waters and/or K. Jorae Jefferson.

I, the undersigned, am in full agreement that colonic irrigation is not a proven method, cure or treatment of disease or condition, nor has it been portrayed as such. Colon irrigation in this facility is a self-administered procedure where I, as the user of the device, am solely responsible for my own actions and release liability regarding my health issues. The device being utilized in this facility is a FDA registered Class II gravity device that can be used to do endoscopic procedures. I understand I will self insert my own speculum and iwll be in full control of the procedure. I am aware not all states have laws governing the use of colon irrigation/enema devices. The facility I have chosen is aware of the laws governing the facility at the time I sign this waiver of consent and that at anytime those laws can change an neither I, my family, nor my representative(s) will hold the equipment manufacturer, facility or their employees responsible for my personal choice to receive colon irrigation at this facility nor hold them liable for any changes or variations of the law after the time of my dated signature below. All results of my session(s) are contributed to research and the utilization in future programs of Self Health Aid, while preserving my privacy, I waive any liability on behalf of the technician serving me.