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?