Health Coach Client Intake Form

Health Coach Client Intake Form

Bellaire Wellness Spa
Personal Details
Full Name

First NameLast Name
Age
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Company Name
Emergency Contact Person

First NameLast Name
Emergency Contact Phone No.
Please enter a valid phone number.
Best time to call

Hour Minutes

AM/PM Option

Current Health Statistics
Blood Type
Weight (kg)
Height (cm)
Body Mass Index (BMI)
Appointment
Preferred Day/Days

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Time

Hour Minutes

AM/PM Option

Terms and Conditions
- I confirmed that all information in this form is accurate and try to the best of my knowledge.
- I confirmed that I have read the contents of this form including these terms and agreement.
- I understand that this clinic or health facility will protect all the information in this form and will keep it confidential.
- I understand that this clinic/facility accepts cash, check, and credit cards for payment methods.
- I understand that this procedure is not considered professional advice. It is recommended to seek professional advice from professionals like lawyers, physicians, spiritual, and financial.
- I confirmed that I have the right to terminate this care at any time.
- I released this clinic or facility from any liabilities like injuries, accidents, or damage that might happen during the procedure.
- I understand that this procedure doesn't guarantee specific results or outcomes.
Patient Signature

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Date Signed

MonthDayYear
Date
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