THE LION KING - Personal Intake Form

THE LION KING - Personal Intake Form

*Confidential information for Management only*
Email*
example@example.com
Legal Name*
Professional Name (if different from above)
Local Address*

Local Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Permanent Address*

Local Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Cell Phone Number*
Home Phone Number
Pronouns*
Social Security*
Date of Birth MM/DD/YYYY*

MonthDayYear
Date
LKNY Start Date MM/DD/YYYY*

MonthDayYear
Date
Department*
Emergency Contact Info

Please enter your emergency contact's
Name*
Relationship*
Pronouns*
Phone*
Address*
CityStateZip*
Other Phone
Medical Information

Please enter "N/A" if the answer is "No" to any of the questions below.
Do you have any allergies? Please list below.*
Is there any medical condition, prescriptions, medical implants to which paramedics or hospitals should be alerted to?*
Do you wear contacts or glasses?*
Do you have a preferred doctor? Please include their name and phone number below.*
Dietary Restrictions
Please share any dietary restrictions that we should be aware of (i.e. vegan, vegetarian, gluten-free, dairy-free, etc.)*
Anything else you would like us to know
Please let us know your t-shirt size below.*
Should be Empty: