Master Patient Intake and Consent Agreement

Master Health & Intake Form

Patient Intake & Consent Agreement
Holistic Health Sanctuary

Patient Intake & General Consent Agreement
Patient Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Information and Medical History
1. How would you describe your current overall health?
2. Please check any medical conditions or health concerns that apply to you
3. Please list all current Medications and Supplements
4. Skin History
5. Please list all allergies and sensitivities
6. Recent Treatments including face and body
7. Pregnancy and Breastfeeding
8. Please provide your health provider information
9. Acknowledgement
Treatment Goals and Expectations
1. What are your primary goals for receiving services at HHS?
2. Please describe your specific goals, concerns, and what you hope to achieve through your treatments
3. Have you received similar aesthetic wellness or skincare treatments before? If yes, please describe your experience.
Consent to Services and Treatment Acknowledgement
1. General Consent to Treatment:

I understand that HHS provides wellness, aesthetic, and skincare services designed to support my personal goals. I voluntarily consent to receive services and understand that individual results vary. I understand that no specific outcome or result is guaranteed.
2. I understand that aesthetic and wellness services may involve potential risks, including but not limited to temporary redness, swelling, sensitivity, discomfort, bruising, irritation, allergic reaction, changes in pigmentaiton, infection, or other unexpected responses. I understand that my individual response may vary based on my health, skin condition, lifestyle, and other factors.
3. Client Responsibility
4. Questions or ConcernsPlease list any questions, concerns, or specific areas you would like addressed before treatment.
Appointment Cancellation & No Show Policy
Appointment time is reserved specifically for you. If you need to cancel or reschedule your appointment, please provide at least 24 hours’ notice.

Appointments canceled or rescheduled with less than 24 hours’ notice, as well as missed appointments (“no-shows”), will be subject to a cancellation fee of $50 and/or forfeiture of any deposit or prepayment, as permitted by applicable law and any applicable booking terms. All first time bookings require full session price paid in advanced. First time bookings and Groupon bookings that cancel last minute (day of booked session) will forfeit full value of service and/or Groupon voucher.

Repeated late cancellations or missed appointments may result in limitations on future appointment scheduling.

By signing this agreement, you acknowledge that you have read, understand, and agree to this Appointment Cancellation & No-Show Policy.
Release of Liability, Assumption of Risk and Hold Harmless Agreement
1. Release Agreement

I acknowledge that I am voluntarily choosing to receive services from HHS. I understand that aesthetic, wellness, and skincare services may involve inherent risks, and I voluntarily accept responsibilty for any risks associated with receiving these services.
2. Services Provided, Informed Consent, and Release of Liability

I understand that Holistic Health Sanctuary (HHS) offers a variety of wellness, aesthetic, therapeutic, and complementary health services. I acknowledge that services offered may change over time, vary from month to month, and are not limited solely to the procedures listed below.

Services may include, but are not limited to:

Manual Lymphatic Drainage
Microdermabrasion
Chemical Peels
Signature Facials
Microneedling
High Frequency Therapy
Radio Frequency (RF)
Electromuscular Stimulation (EMS)
Microcurrent Therapy
Ultrasonic Cavitation
Lipo Laser
Hair Removal Treatments
Therapeutic Body Massage
Reiki
Energy Healing
Sound Bath Therapy
Hypnotherapy
Peptide Therapy
Infrared and Red Light Therapy
Acupressure
Fractional Radio Frequency (Fractional RF)
High-Intensity Focused Ultrasound (HIFU)
Sound Wave Therapies
Body Cupping
Neuromodulator Injections (including Botox® or equivalent products)
Dermal Fillers
PDO Thread Treatments
I understand that the above list is intended as a representative list of services and is not exhaustive. Holistic Health Sanctuary may introduce, discontinue, or modify services as deemed appropriate.

I acknowledge that any procedure or treatment I elect to receive may be performed by a qualified practitioner affiliated with Holistic Health Sanctuary or by an independent practitioner within the Holistic Health Sanctuary professional network, depending upon the specific service provided.

By signing this agreement, I voluntarily consent to receive services that I have selected and discussed with my practitioner. I acknowledge that all treatments carry inherent risks, benefits, limitations, and potential complications, which have been explained to my satisfaction or for which I have had the opportunity to ask questions.

To the fullest extent permitted by law, I release, indemnify, and hold harmless Holistic Health Sanctuary, its owners, employees, contractors, practitioners, affiliates, and members of its professional network from any claims, demands, damages, liabilities, or causes of action arising from or relating to the services provided, except in cases of gross negligence or willful misconduct.
3. Assumption of Risk

I understand that while HHS will provide sevices with reasonable care and professionalism, results may vary and there are no guarantees regarding outcomes. I acknowledge that I have had the opportunity to ak questions and rceive information regarding the services I may receive.
4. Hold Harmless Agreement

To the fullest extent permitted by law, I agree to release, waive, discharge, and hold harmelss HHS and it owners, employees, contractors, and representatives from claims, liabilites, damages, or expenses arising from my voluntary participation in services, except in cases of gross negligence or willful misconduct.
5. Medical Disclosure Requirement
6. Consent to Photos- May HHS take photographs of treatment areas for documentation, progress tracking and marketing?
Patient Authorization & Electronic Signature
1. Final Acknowledgment/ Required
2. Patient Signature
3. Today's Date

MonthDayYear
Date
4. Practitioner's Notes:
Should be Empty:

Master Health & Intake Form

Holistic Health Sanctuary

Patient Information

Emergency Contact Information

Health Information and Medical History

Treatment Goals and Expectations

Consent to Services and Treatment Acknowledgement

Appointment Cancellation & No Show Policy

Release of Liability, Assumption of Risk and Hold Harmless Agreement

Patient Authorization & Electronic Signature