Client Intake Form

Client Intake Form

Initial Visit
Contact Information*

First NameLast Name
D.O.B.*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about us?*
Referral Code?
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Please Read The Following And Sign Below:

Please note: It is our policy to not provide Assisted Lymphatic Therapy services if you are pregnant, have a pacemaker, have congestive heart failure, or deep vein thrombosis.

I confirm that I have made ALL past and present medical conditions known. If suggested by Haven Health & Wellness, I will consult my physician or health care provider prior to my visit, and provide Haven Health & Wellness with said information. I understand that Haven Health & Wellness does not provide a medical diagnosis.

I understand if I am receiving Assisted Lymphatic Therapy, I hereby declare that I have provided all relevant information necessary for the proper application of this therapy and I agree to hold harmless, release and indemnify this therapist. I expressly give my permission for this therapist to provide such therapy.

By signing below, I certify that I have read and understand the statements above and consent to the therapy.
Referring Practitioner (if applicable):
Client Signature*

Clear
Date*

MonthDayYear
Date
All Haven Health & Wellness therapists are trained and certified by Rightway Health and Wellness. IF YOU ARE A FEDERAL, STATE OR LOCAL AGENT, UPON ENTERING THESE PREMISES, YOU MUST DECLARE SAME UNDER THE BIVENS ACT- ARTICLE 42, AND BE HELD PERSONALLY AND INDIVIDUALLY LIABLE.
Significant Past Illnesses (Please list Illness, Year(s), and any comments)*
Previous Surgeries (Please list Illness, Year(s), and any comments)*
Present Health Problems (Please list Medical Problem, Date of Onset, and any comments/Concerns/Symptoms)*
General overall health currently*

ExcellentGoodFairPoor
Indications/Contraindications:

Depending on what you answer "yes" to in this section, we may not be able to provide a Lymphatic Service. Your therapist will reach out to you if there is a concern.
Do you have a pacemaker or any other electrical medical devices?*

YesNo
Have you had any organ transplants?*

YesNo
If yes, explain...
Are you pregnant?*

YesNo
Do you have a "diagnosed" deep vein thrombosis (DVT)?*

YesNo
Do you have Congestive Heart Failure?*

YesNo
Do you suspect you might have a blood clot?*

YesNo
Have you had lymph nodes removed? If yes, how many?*
Additional Questions
Please Select All That Apply:

Headaches/MigrainesSinus CongestionChronic PainAuto-Immune Dysfunction/DiseaseSwollen Lymph NodesFluid in EarsLymphedema (Swelling)TMJMold ExposureHeavy MetalsExcess Water RetentionAcneEczema/PsoriasisNeuropathyNauseaCoughArthritisHormone Imbalance
Is the use of oils on your skin permissible?*

YesNo
Please Answer All Questions
Have you ever been diagnosed with any breast disease (fibrocystic, mastitis cystic, abscess)?
Have you had any breast cosmetic surgery or implants? If yes, under or over muscle? Saline or Silicone?
Do you have any botox or filler? If yes, please explain.*
Do you have any "Aesthetics" you wish to be worked on? (ex. acne, eczema, baker's cyst, scar(s), raised mole(s), skin tag(s), stretch marks, etc.)
* Please note that any "Aesthetic Add-On" is an additional $15 (per problem area) to your ALT session. This adds ~10 minutes to your appointment time.*
If there is any additional information worth noting, please list here.
Authorization to Use or Disclose Protected Health Information
As required by the Privacy Regulations, Haven Health & Wellness, may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize Haven Health & Wellness and any of its employees to use or disclose my Client Health Information to the following person(s), entity(s), or business associates of this office:

- Client's Physician or Health Care Provider (if applicable)

I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.

I understand I have the right to:

1. Revoke this authorizatiton by sending written notice to Haven Health and Wellness and that revocation will not affect this company's previous reliance in the use or disclosure pursuant to this authorization.

2. Have knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.

3. Inspect a copy of Client's Health Information being used or disclosed under federal law.

4. Refuse to sign this authorization, however by doing so, we will not be able to provide our services.

5. Receive a copy of this authorization.

6. Restrict what is disclosed with this authorization.
Cancellation & Reschedule Policy
We understand that things happens that keep you from being able to make your scheduled appointment. This being said, we kindly ask that you inform us at least 24 hours before your appointment time, so we can plan accordingly.

If you do not appear for your scheduled appointment and you have not contacted us via phone (we do not accept cancellations by email or text), we reserve the right to charge a cancellation fee equal to the cost of your booked service.

If you are running late for your appointment, please call us. We will do our best to accommodate you or reschedule your appointment.

By signing below, I agree that I have read and understand the information listed in this document. I agree to all terms, conditions, and policies listed above.
Signature of Client or Client's Authorized Representative*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Intake Form

Indications/Contraindications:

Additional Questions

Please Answer All Questions

Authorization to Use or Disclose Protected Health Information

Cancellation & Reschedule Policy