Consent and Release - Colon Hydrotherapy Institute

I, *

First and Last Name

Certify that I am over the age of 18, or that I am the parent/guardian of

For receiving services, products, information and education, I release and discharge Shelby Molchan and Colon Hydrotherapy Institute from any and all responsibility or liability that may arise from using these services, products, information and education. No guarantees have been made to me as to the success, value or benefit of Colon Hydrotherapy treatments, other services, products, information and education offered at Colon Hydrotherapy Institute. I realize and acknowledge that the services and information received at Colon Hydrotherapy Institute are not a medical treatment. I am aware that Colon Hydrotherapists are not physicians and therefore do not diagnose, prescribe or treat any illness or condition. I understand that Colon Hydrotherapy is not a medical procedure and is not covered by insurance companies. Shelby Molchan and Colon Hydrotherapy Institute do not claim to treat or cure any condition or disease. Any services provided or products sold are used solely at the client’s discretion. Kindly give 24 hours notice of cancellation in the event you are not able to make a scheduled session. Shelby Molchan reserves the right, at her discretion, to enforce a broken appointment charge in the event of ‘no-show’. Broken appointment charges are the full price of one session. *

Signature

Date

Name