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Contact Form

*Name:
Phone:
Address: City:
Age: Birth date:
Email: Referral:
Are you under doctors care?

Yes no
explain:
Have you ever had Colonic Irrigation or Enemas before?
Yes no
If you have been diagnosed with or suspect you have the following:
Yes no

Acute Liver Failure

Chrohn's Disease

Anemia


Hemorrhoidectomy

Carcinoma of the Colon


Intestinal Perforations

Diverticulitis

Rectal Surgery

Fissures & Fistulas


Abdominal Surgery

Renal Insufficiency


Cardiac Conditions

Abdominal Hernia


Dialyses Patient

Aneurysm


Hemorrhaging

Pregnant

Lupus
Do you currently have any of the following?
Yes no
Difficult sleeping Burning stomach
Heart trouble Bad breath
Extreme stress Rectal bleeding
Malignant condition Skin problems
Indigestion after meals Rectal surgery
Burning/Itching anus High blood pressure
Use laxatives Colon surgery
Stool very foul odor Alcoholic
Bladder infection Irritability
Vomiting BM painful/difficult
Recent surgery Sour stomach frequently
Infectious disease Strain depression
Asthma Abdominal gas
Hemorrhoids Diverticulums'
Recent barium enema colons Blood in stool
*We will call you back to confirm date and time of your appointment.
*Please Call for an appointment
Form is under construction

Specials and Packages

Colonics - Single Visit $70.00 Massage Therapy - Single Visit $80.00

$160 - package of 3 or more Colonic Sessions
$53.00 each (total Savings $50.00)
* must be used within 3 months of purchase

Schedule your appoinment Monday - Friday
From 9am - 2pm and pay only $65.00

$180 - package of 3 or more Colonic Sessions
$60.00 each (total Savings $30.00)
* must be used within 6 months of purchase

Package of 10 or more Massage Therapy Sessions
$600.00 / $60.00 each (total Savings $200.00+)