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					                                   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.

            Print Name__________________________________________________________________

6001 Arlington Blvd., Suite T-13                                                                                703-820-6460
Falls Church, VA 22044                                                                                          703-987-4450