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MEDICAL AUTHORIZATION TO PURCHASE COLON IRRIGATION SYSTEM
USE THIS FORM OR PHYSICIAN CAN USE PRESCRIPTION PAD
This authorization permits ______________________, (you or your company name:
hereafter “Client”) to purchase _____________, (number) of ANGEL
OF WATER COLON IRRIGATION SYSTEM(s), under the following terms and conditions:
Indemnity. Client agree to defend, indemnify and hold the physician authorizing purchase harmless against any losses, expenses, costs or damages reasonable attorneys' fees, expert fees' and other reasonable costs of litigation arising from, incurred as a result of, or in any manner related to (1) Client's breach of the terms of this agreement, (2) Client's unauthorized or unlawful use of COLON IRRIGATION SYSTEM(s) covered under the terms of this agreement, (3) the unauthorized or unlawful use of COLON IRRIGATION SYSTEM(s) covered under the terms of this agreement by any other person, (4) the actions of the physician authorizing purchase (so long as he is not negligent or his actions do not constitute willful misconduct).
Applicable Law; Legal Action. This Agreement and all related documents shall be governed by and interpreted according to the laws of residence of physician, and venue of any dispute or litigation relating or arising out of this agreement. The physician in any arbitration or litigation shall be entitled to judgment against the Client for reasonable attorney's fees and costs paid or incurred, including such fees and costs on appeal.
Entire Agreement. This agreement, contains the entire agreement between client and the physician authorizing purchase relating to the subject matter hereof, and supersedes any other oral or written communications relating thereto.
Client’s Responsibilities. Client shall be responsible for assigning staff members or external service to administer the COLON IRRIGATION SYSTEM(s) program to insure compliance with local and national protocols and regulations. Compliance with local and national protocols and regulations is the sole responsibility of the Client. The following COLON IRRIGATION SYSTEM(s) is for use by you and your staff; the physician authorizing purchase approves COLON IRRIGATION SYSTEM(s) use by appropriately trained Client’s employees only.
Training Program Information. Client agrees that all personnel authorized to use the COLON IRRIGATION SYSTEM(s) will be trained utilizing a training program that conforms to nationally recognized standards for COLON IRRIGATION SYSTEM(s), and that meets state requirements for COLON IRRIGATION SYSTEM(s) training. Client agrees to carefully review manufacturer’s COLON IRRIGATION SYSTEM training & operation manuals, videos etc., and attend classes when and if advised by manufacturer. It is the sole responsibility of the Client to operate the COLON IRRIGATION SYSTEM according to manufacturer’s safe operating standards and Client agree to defend, indemnify and hold the physician authorizing purchase harmless against any losses, expenses, costs or damages reasonable attorneys' fees, expert fees' and other reasonable costs of litigation arising from, incurred as a result of, or in any manner related to Client's improper use of equipment.
Client is certified by. Colon Therapy Nursing Foundation (CTNF.org) ___; International Association of Colon Therapists (I-Act)___; Australian Colon Hydrotherapy Association ___; Association & Register of Colon Hydrotherapists(London) ____
Uses of Colon Irrigation System. When patient has scheduled a radiological or endoscopic exam requiring bowel evacuation within 48 hours or when medically indicated for constipation. Client agrees to use ONLY water for colon irrigation. NO other liquids should ever be used to irrigate colon.
Contraindications for use. Severe abdominal pain in area of sigmoid colon; noticeable
blood in feces; congestive heart failure; diverticulitis; ulcerative colitis;
Crohn's disease; severe or internal hemorrhoids; tumors in the rectum or colon
; intestinal perforation; carcinoma of the rectum; fissures or fistula; abdominal
hernia; renal insufficiency; recent colon or rectal surgery; cirrhosis of the
liver ; first and last trimester of pregnancy.
Safety Perameters. Patient must be in satisfactory physical and emotional condition to tolerate procedure as demonstrated by: Blood Pressure: Systolic 100-150, Diastolic 60-100; Heart Rate: 55-100; Clear Lung Sounds; SpO2: > 95%; Bowel sounds all 4 quadrants; (-) GUAC test; Alert & Oriented X 3; Patient has no known unresolved history of Post Traumatic Stress Disorder that might cause further emotional trauma from Colon Irrigation procedure.
Client Name ______________________________ Authorized Title ______________
Company____________________________________________________________
Client_SignatureX______________________________ Date _________________
__________________________________________________________ (street)
______________________________ (city) ________(state) ____________ (zip)
On-Site COLON IRRIGATION SYSTEM Coordinator __________________________
Phone Number ______________________________ Fax Number _______________________
E-mail ______________________________
MEDICAL AUTHORIZATION TO PURCHASE ______THE ANGEL OF WATER COLON IRRIGATION
SYSTEM(s) & Rectal Nozzles with Flex Tubes PRN (as needed) for one year.
Physician authorizing purchase:
NAME:___________________________________ License #_________________________________
SIGNATURE:X__________________________________________Date _____________
USE THIS FORM OR PHYSICIAN CAN USE PRESCRIPTION PAD
Fill Out & Fax to Jim Bock, RN at fax# (908) 598-7449
QUESTIONS CALL (800) 834-9945 or (908) 451-5748
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