Alazan Care

*Name:

Phone:

Alt. Phone::

Address:

City:

State: Zip:

Appointment Date:

Age:

Birth date:

Email:

Referral:

Are you under doctors care?

Yes no explain:

Please list any medications, or anything else we should know about?

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

If you have any questions or to schedule an appointment, please contact us at:
972-380-4845

Our address is:

17810 Davenport Rd., Suite 108
Dallas, TX 75252