Master’s Health & Wellness Center
Rejuvenating the Body for Vibrant Health
Colon Hydrotherapy Consent Form
Neither Master’s Health & Wellness Center nor their associates do the any of the following
things, either implied or intended:
1. We do not diagnose.
2. We make no attempt to cure any condition.
3. We make no claims or imply any claims that suggestions are given to cure any
4. We do not claim that any supplemental material we may speak about will cure
any condition, or that its' purpose is to treat any condition.
5. We do not prescribe or treat disease, however, we do attempt to educate you in/on
dietary recommendations and exercise if it is not contradictory to the
recommendations of your primary physician.
What is Colon Hydrotherapy?
Colon hydrotherapy is a safe, effective method of removing waste from the large intestine
without the use of drugs, within a comfortable environment. Colon hydrotherapy, also called
colonics, or colon irrigation, is a procedure whereby a soothing flow of filtered temperature –
regulated water is gently introduced into the rectum via a disposable rectal nozzle to cleanse the
contents of the lower colon. This procedure enables waste to be softened and loosened, resulting
in evacuation of old, hardened, waste material and harmful toxins through natural means. Colon
hydrotherapy works in several ways: cleansing, exercising, and reshaping the colon, as well as
stimulating reflex points. It can stimulate the immune systems, provide a favorable environment
for digestion and allow for better absorption of nutrients. It may help eliminate distortions of the
colon and narrow, spastic constrictions so that the colon gradually begins to resume its natural
I, the undersigned client, understand the above statements. By signing this form, I give my
consent to a colon hydrotherapy session. I understand I may discontinue a session at any time. If
I have been diagnosed by a licensed health professional as having any disease, injury, or other
physical or mental condition, I understand that I should inform the person who made the
diagnosis, about the treatment I will be receiving, and whether or not I intend to discontinue any
treatment or therapy which has been previously ordered, prescribed or recommended by a
licensed health professional
I understand that diet and nutrition is considered to be an inexact science and that the results
obtained are not always constant or predictable. I also understand that there is no guarantee of
any results and the opposite of the desired results may appear. Whether or not I participate in this
procedure or program is my decision, based on my constitutional right of the Ninth Amendment.
All decisions relative to my well being and health must be made by me. I further understand that
Master’s Health & Wellness Center staff are not medical doctors and are not attempting to
portray themselves as or conduct the activities of medical doctors.
6001 Arlington Blvd., Suite T-13 703-820-6460
Falls Church, VA 22044 703-987-4450