Colon Hydrotherapy Consent

I am requesting that Colon Hydrotherapy be provided to me under the supervision of the staff at the Sharma Holistic Center. I have been informed and fully understand that Hydro-Colon Therapy has been presented to me as a hygienic method of cleansing the colon by filter water. I also understand and agree to have Sharma Holistic Staff member performing the procedure to massage and insert a disposable speculum into my anus and rectum in order to assist me in cleansing my large intestine. This is not a routine treatment for the colon and I have not been promised or guaranteed any specific benefits from the therapy for candida, irritable bowel syndrome, constipation or any other condition for which this treatment is being offered. While I am not making any commitments to any particular number of treatments, I acknowledge that I have been recommended to undergo an initial series of treatments. Upon completion of this series, I plan to take further treatments as prescribed.

I have been informed that the insurance companies do not usually pay for this therapy and I agree to pay for the treatments myself.

I release Dr. Sharda Sharma and/or any individual staff member providing me with medical services with respect to this colon hydrotherapy procedure. I understand that this is a voluntary procedure and this is a holistic method of remedying the conditions I have complained of and that there is no further guarantee as to the result of this treatment.

I understand that the program that I choose to participate in is a program that may or may not result in benefits to me and release Sharda Sharma, M.D. and / or any individual staff member from any adverse result of participation in such program. Although it is anticipated that proper participation and continuation in this program may lead to positive results, neither Sharda Sharma, M.D. nor her staff have promised any definitive beneficial results.

I have read all of the above and have the information given to me on colon hydrotherapy so that I fully understand what I am signing and hereby request and consent to these treatments.