COLON HYDROTHERAPY TRAINING APPLICATION:

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip Code *

Phone Number *

Date Of Birth *

Current Profession

Previous Profession

Educational Degrees

Have you had colon hydrotherapy sessions?
YesNo

Was it a closed system with disposable tubing?
YesNo

Do you have a medical condition that requires you to take medications daily?
YesNo

Please list three of your strengths

Please list three areas where you’d like to grow

Why are you interested in participating in this course?