Kerala Ayurveda Clinic

173 Belgrave Gate Leicester LE1 3HS

Colon Hydrotherapy Form

Please give the following contact details and tick your preferred method of contact

Please answer the following as accurately as possible
If Yes, please give details below

Do you suffer from any of the following – please tick
If Yes, please state when
If Yes, please state when
If Yes, please state when
If Yes, please state when
If Yes, please state when
If Yes, please state how many a day
If Yes, please state how much a week
If Yes, please state when
If Yes, please describe

General Bowel Movements

If Yes, what do you take?
How would you describe your bowel movements? Please tick where appropriate
Do you suffer from any of the following? Please tick where appropriate


I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if recommended by my Therapist
Colon Hydrotherapy is a safe and effectively cleanses your large intestine –colon. Your Therapist does not diagnose disease or prescribe medications. Should any of your responses to any of the above questions contraindicate colon hydrotherapy you will be advised to seek your doctor’s help. It is responsibility to provide full and complete answers so your Therapist can treat you correctly. Also you must inform us of any changes to your health between treatments.

General Data Protection Regulations (GDPR)


Please answer the following

All the information I have given is accurate and correct and I have not withheld any information about my health. I will keep informed of any changes regarding my health in the future by writing. My Ayurveda Consultant/Therapist has explained the effects and benefits of Ayurveda therapies/Complimentary or beauty therapies and possible effects that may occur as a result, including redness, pain, bruising, some minor reaction, and other contra-indications. I recognize that my participation is voluntary and that I am happy to proceed. I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. If I am not able to make a scheduled appointment, I agree to cancel the appointment by giving 24 hours’ notice before the booked appointment. If I miss a scheduled appointment without giving 24 hours’ notice, I agree to pay for my missed appointment charge.