Colon Hydrotherapy Emergency Contact & Health Screening Form

Safe & Compliant Colon Hydrotherapy Intake

Colon hydrotherapy is a wellness treatment that requires careful client screening to ensure safety and identify potential contraindications. This Colon Hydrotherapy Emergency Contact & Health Screening Form helps wellness centers, naturopaths, colon hydrotherapists, and holistic health clinics collect essential medical history, emergency contact details, and informed consent before treatment.

Whether you're running a standalone colon hydrotherapy practice, a wellness spa, or an integrative health clinic, this template ensures you capture the critical information needed to provide safe, responsible care while protecting your practice from liability.

Why This Form Matters

Colon hydrotherapy involves introducing water into the colon, which can pose risks for clients with certain medical conditions—including active bowel disease, recent abdominal surgery, intestinal perforation history, pregnancy, or severe hemorrhoids. This form helps you identify contraindications before treatment begins, ensuring client safety and informed consent.

By collecting detailed health history alongside emergency contact information, you create a complete client record that supports clinical decision-making and provides documentation in case of adverse events.

What This Template Includes

This form is designed specifically for colon hydrotherapy practitioners and includes:

• Personal and contact information to identify the client
• Emergency contact details with relationship and phone number for rapid response
• Medical history screening covering bowel diseases, gastrointestinal conditions, and relevant diagnoses
• Recent surgery questions to identify clients who may need medical clearance
• Pregnancy status verification to screen for contraindications
• Intestinal perforation and risk factor assessment to identify high-risk clients
• Current symptoms screening including abdominal pain, bleeding, or active infection
• Medication and health condition disclosure to understand the full clinical picture
• Informed consent and risk acknowledgment confirming the client understands potential complications
• Signature field for legal documentation

Perfect for Healthcare and Wellness Professionals

This template is ideal for:

• Colon hydrotherapists providing colonics in standalone clinics
• Naturopathic doctors offering colon hydrotherapy as part of detox programs
• Wellness spas and retreats with colon hydrotherapy services
• Integrative medicine clinics combining conventional and alternative therapies
• Holistic health practitioners supporting digestive wellness

Streamline Client Safety with Paperform

With Paperform, you can customize this template to match your practice's specific protocols, add your branding, and integrate with your existing systems. Use conditional logic to show follow-up questions only when certain conditions are flagged, ensuring a smooth client experience while capturing all necessary detail.

Connect to your practice management system via integrations with tools like HubSpot, Google Sheets, or Airtable to maintain organized client records. Set up email notifications to alert your team immediately when a high-risk condition is disclosed, so you can follow up before the appointment.

For practices that need clients to sign consent forms after screening, Papersign (papersign.com) makes it easy to send professional eSignature documents directly from form submissions, keeping your intake and consent process connected and compliant.

If your clinic requires multi-step workflows—like flagging contraindications for provider review, sending pre-treatment instructions, or scheduling follow-up consultations—Stepper (stepper.io) can automate those handoffs without coding, ensuring nothing falls through the cracks between intake and treatment.

Build Trust Through Transparent Safety Protocols

Clients appreciate practitioners who take safety seriously. By using a detailed, professional intake form, you demonstrate your commitment to responsible care and informed consent—building trust and reducing liability exposure.

This template helps you meet industry best practices for colon hydrotherapy screening while creating a seamless, reassuring experience for clients. Customize it to reflect your clinic's tone, add your logo and colors, and embed it directly on your website or send it as a standalone link before appointments.

Get Started in Minutes

Paperform's doc-style editor makes it easy to adapt this template to your needs. Add or remove questions, adjust language to match your practice's voice, and set up automated workflows that save time and reduce administrative burden. Whether you're a solo practitioner or managing a multi-provider wellness center, this form scales with your practice.

Start with this template today and create a safer, more professional client intake experience for your colon hydrotherapy practice.