Wellness Consultation Intake - Be Well LifeStyle Centers

Basic Information

How did you hear about us?

Referred By (name, if applicable)

Is this form being filled out for a minor (under 18)?

No Yes

First Name

Last Name

Date of Birth

/ /

Gender at Birth

Mobile Phone

Email Address

Address

Street Address

Apartment, Suite, etc. (Optional)

City

State

ZIP Code

Visit Details

Preferred Clinic Location

Is this your first visit to Be Well?

Emergency Contact Name

Emergency Contact Phone

Services & Goals

What brings you to Be Well?

What are your primary health goals?

Current symptoms you'd like to address

Interested in our 12-Week Total Transformation Program?

When would you like to start?

Preferred appointment times

Medical History

Allergies (or leave blank if none)

Current medications:

Current supplements:

Past surgeries or hospitalizations:

Do you have any of the following conditions? Check ALL that apply:

Are you pregnant or breastfeeding?

Are you taking any blood thinners?

Tobacco/Nicotine use:

Alcohol consumption:

Have you had IV therapy or injections before?

Any previous adverse reactions to IV therapy, injections, or blood draws?

Have you ever fainted, felt dizzy, or had a reaction from an injection, IV, or the sight of blood?

Lifestyle

What is your work / exercise activity level?

Do you follow any special diet?

How much water do you drink daily?

On a scale of 1-10, how motivated are you to achieve your health goals?

1 - Not motivated 10 - Extremely motivated

5

Document Uploads (Optional)

Driver's License or ID Choose file

No file chosen

Insurance Card (Front & Back) Choose file

No file chosen

Recent Blood Work Choose file

No file chosen

X-rays, MRI, or Other Medical Records Choose file

No file chosen

Insurance Information

Is the insurance under your name?

Primary Insurance Holder Information:

First Name

Last Name

Date of Birth

/ /

Relationship to You

Consent & Electronic Signature

I have read and agree to the terms above *

Date

Full Legal Name (This acts as your electronic signature)

I agree that by typing my name above, I am electronically signing this form. I understand that my electronic signature is legally binding and has the same legal effect as a handwritten signature, pursuant to the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN) and applicable state laws.

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Wellness Consultation Intake Form

Please complete all sections of this form.

Basic Information

Guardian / Parent Information

Address

Visit Details

Services & Goals

Medical History

Do you have any of the following conditions? Check ALL that apply:

Lifestyle

Document Uploads (Optional)

Insurance Information

Primary Insurance Holder Information:

Consent & Electronic Signature

Wellness Consultation Intake Form

Please complete all sections of this form.

Basic Information

Guardian / Parent Information

Address

Visit Details

Services & Goals

Medical History

Do you have any of the following conditions? Check ALL that apply:

Lifestyle

Document Uploads (Optional)

Insurance Information

Primary Insurance Holder Information:

Consent & Electronic Signature

Full Disclosure

Assumption of Risk

Release of Liability

HIPAA Consent