Client Intake and Consent Form
A new client form for a wellness or health practice, with the client's consent to the service. Template v1.0.
Date: Date
Practice: Practice
Service: Service
Practitioner: Practitioner
1. Client details
The client (the Client) fills in this form before the first appointment with the practice named above (the Practice).
Date of birth (optional): Client fills this in when signing
Phone: Client fills this in when signing
Email: Client fills this in when signing
Emergency contact name and phone: Client fills this in when signing
2. Health information
This helps the practitioner give the service safely. The Client should mention anything that may matter, even if it seems minor.
Health conditions, injuries or allergies (optional): Client fills this in when signing
Medications and supplements (optional): Client fills this in when signing
The Practice keeps this information private and uses it only to provide care, as the privacy law where it operates requires.
The information on this form is true and complete, and the Client will tell the Practice about any change. Client
3. Consent
The practitioner will explain the service and check in during it. The Client may ask questions or ask for changes at any time.
The Client understands the service is not a substitute for diagnosis or treatment by a doctor, and that they may stop it at any time. Client
The Client consents to receive the service named above. Client
4. Cancellation policy
The Client agrees to the cancellation policy above. Client
