Appt Request

New Client Colonic Appointment Request Form

If you are a returning client or looking to schedule an ion foot cleanse please text or call 561.617.0607
Please read over the appt hold policy and contraindications. The video shows the open colonic process that's featured at Spa Lavage. Please complete the questions at the bottom of this request then hit submit. Once complete I'll propose a date / time. Once agreed, I'll send an invoice for the appt hold. If you have additional questions that aren't answered in this form please text me 561.617.0607 the questions or request a phone call.
Appt Hold Policy

The fee is $125, split into twp installments. $50 (paid by invoice) at the time of booking to secure the appt time. The remaining $75 due at the time of service.

I require a $50 appt hold fee to secure the first appt. It deducts from the total of $125 and if a cancellation is needed, please give at least 4 hours notice before your scheduled appt by either a text or phone call/VM to receive a full refund less the processor’s fee of $1.95.
Contraindications

The following is a list of contraindications for colon hydrotherapy. If you have ever been diagnosed with any of the following, a doctor’s prescription/release is required before your appointment:

Abdominal hernia (current and not repaired)

Abdominal surgery (recent)

Abdominal distention/masses

Acute Liver Failure

Anemia (severe)

Aneurysm

Carcinoma

Cardiac condition

Crohn's Disease

Colitis

Dialysis patient

Digestive disorder history

Diverticulosis

Fissures

Fistulas

Hemorrhaging

Hemorrhoid surgery (recent)

Intestinal perforations

Lupus

Pregnant (currently)

Rectal surgery (recent)

Renal (kidney) Insufficiencies
Youtube-Open Colonic Process
Name*

First NameLast Name
Cell Phone Number (capable of accepting texts)*
Please enter a valid phone number.
Are you looking for the first available appt time or a specific date / time?*

ASAP (skip answering date and time)Specific date and/or time (please select the date and time below)
What is your desired date for this appt?
Time

Hour Minutes

AM/PM Option
Do you have previous experience with "open system" colonics? "Open system" is more personally directed than other methods. The therapist does not administer, but facilitates this style colonic (watch video above to see process)*

YesNoStill unsure
What is your sex?*

MaleFemalePrefer not to say
What Is your T-shirt size?*

Small / MediumLargeX LargeXX Large
Should be Empty:

New Client Colonic Appointment Request Form