Jluvessentials: Medical History Intake Form

🎀JLE: Health & History Form 🎀
First Name:
Last Name:
Health Card #:
9 digit #
Height:
inches & ft
Occupation:
job, career, school etc.
Date:

MonthDayYear
Date
Weight:
Email:
example@example.com
Referred by:
friend,post,ad etc.
Birthdate:

MonthDayYear
Date
Address:
F/M
City:
F/M
Province:
F/M
List all medications being taken now & last 6 months:
Do you smoke? If yes, how long?:
click if you have the following: (present in the 6 months- last year)

Hot/Cold intolerancePacemakerMetal implantsMoleshemophiliacancer/chemo/radiationAccutaneclaustrophobiaAttempting to conceive/pregnant/and or breastfeedingElectrical implantsAny active disease or infection: Sexually transmitted
List all allergies:
List all medical & mental health conditions etc.
List your Emergency contact

Guardian, Parent, over the age of 18.
Name

NameLast Name
Sex: F/M
Phone
Address
Postal code
Email
example@example.com
City
Province
Relation
Privacy Policy Outline & Consent:

We collect personal information to ensure all boundaries and areas are being permitted and treated as such. The records will only be present during your specific visits. We may disclose your personal health information only to the extent necessary to:

- Treat and care for you, my client.

- Receive payment for treatment (card info - Plan, administer, and operate for internal & personal needs.

- Conduct quality improvement for my technical services, informational promos, and advertising. - Comply with legal and regulatory requirements to fulfill other purposes required by law.

Resources

Saskatchewan Health

https://www.saskatchewan.ca/residents/environment-public-health-and-safety/environmental-health/personal-service-facilities

PIPEDA

https://oipc.sk.ca/2025/?category=blog
Click to verify: Terms & Conditions

-I take steps to protect your personal information from theft, loss, unauthorized access, copy, modification, disclosure or disposal. - Investigation and monitoring is applied to ensure all personal and medical information I receive is protected.I consent to all JLE's requirements for the Medical History Form, Privacy Policy, agreements, requirements, and disclosure of personal health information agreements/policy.I understand that JLE is seeking all information gathered to perform at her best capabilities with the information provided.I understand if I refuse to sign all documents and agreements for JLE, I will not be able to receive treatment. My deposit will be taken due to results in no service.I hereby authorize JLE to perform, use, and disclose personal health information for purposes listed above. I take steps to protect your personal information from theft, loss, unauthorized access, copy, modification, disclosure or disposal. Your personal and medical information will be protected under PIPEDA federal laws. Monitoring and cautionary protocol is applied to ensure all personal and medical information Jluvessentials receives is protected.
Name
Last Name:
Signature

Clear
Date of signature:
MMDDYYYY
Should be Empty:

🎀JLE: Health & History Form 🎀

List your Emergency contact