Alazan Care

Contact Form

*Name:

Phone:

Address:

City:

State: Zip:

Appointment Date: Time:*

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

*We will call you back to confirm date and time of your appointment.

Please schedule your appointment before you come, no walk-in service available

972-380-4845

Our address is:

17810 Davenport Rd., Suite 108
Dallas, TX 75252

Business Hours

Specials and Packages:

Colonics:	Massage Therapy
Schedule your appoinment Monday - Friday From 9am - 2pm and pay only $60.00	Schedule your appoinment Monday - Friday From 9am - 2pm and pay only $65.00
Single Visit: $70.00 Package of 3 or more Colonic Sessions Plan* $180.00 $60.00 each (Total Savings $30.00+)	Single Visit: $80.00 Package of 10 or more Massage Therapy Sessions* $600.00 $60.00 each (Total Savings $200.00+)