New Client Request Form - Karyn Elise Wellness

Personal Information

Name *

First

Last

Email *

Emergency Contact *

Phone (Emergency Contact) *

Relationship *

Date of Birth *

Primary Physician *

Phone (Primary Physician) *

Date *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

Female
Male
Prefer Not to Say

Personal Health Information

Do you or have you ever had (please select your answer):

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Please explain any yes answers: *

Please list current medications, drugs, or supplements and reason for taking:

Please list any other health providers (i.e. Massage therapist, chiropractor, etc) you are seeing and reason:

Physical History

Do you or have you ever had: (please select your answer):

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Please explain any yes answers: *

Smoking History

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Have you ever smoked cigarettes, cigars, or pipes? *

Yes
No

Packs per day:

Nutrition History

Presently smoking *

Yes
No

Last Smoked:

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Do you consume alcohol? *

Yes
No

Do you consume beverages with caffeine?: *

Are you interested in learning how holistic remedies like essential oils can help your overall wellness? *

Yes
No

How many meals do you eat during the average day: *

Are you on any special diet? *

Yes
No

Emotional History

Have you struggled with depression, anxiety or any other mood disorders that have affected your daily life? *

Yes
No

Please explain any yes answers: *

On a scale of 1-10, 10 being worst how much stress do you have on a daily basis? *

Using the same scale, please rate how well you cope with your daily stress (1-10): *

Do you have a daily spiritual/meditative or other practice for stress reduction? Please explain: *

Family History

Has anyone in your immediate family had:

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Health History Agreement *

I agree that all the information is true.

I agree that I have provided ALL information regarding my health status to the best of my ability. I understand that any information left out could put me at risk for injury or other health problems.

Are you 18 years or older?

Yes
No

WAIVER, RELEASE OF LIABILITY AND CONSENT TO MEDICAL ATTENTION *

In Exchange for my being allowed to participate in Restorative Wellness Center’s, Inc. (AKA One Stop Fitness, AKA karynelisewellness) Programs and opportunities (“the Activity”), I and if am not yet 18 years old, my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following:

1. IDENTIFICATION OF RISKS
I understand that participation in the Activity may involve risk of injury, disability and death.

2. ASSUMPTION OF RISK
I am physically and psychologically ready to participate in the Activity and assume all risks connected with my participation in the Activity, I accept personal responsibility for any liability, injury, loss or damage in any way connected with my participation in the Activity.

3. STATUS OF RESTORATIVE WELLNESS CENTER, INC.
I understand and represent that Restorative Wellness Center, Inc. (including its affiliated organization, directors, officers, sponsors, employees, agents, successors, and assigns) is not my physician and the Activity does not constitute the provision of medical or health care services.

4. WAIVER AND RELEASE
I release and discharge Restorative Wellness Center, Inc and each of its affiliated organizations, directors, officers, sponsors, employees, agents, successors, and assigns from all claims for any liability, injury, loss, or damage in any way connected with my participation in the Activity, whether or not caused in whole or part by the negligence of any of the organizations or individuals mentioned above. I intend for this waiver and release to also apply to my relatives, personal representatives, heir, beneficiaries, next of kin, and assigns who might pursue any legal action or claim for such liability, injury, loss or damage. I further intend that this waiver and release shall be effective indefinitely unless I provide written notification to Restorative Wellness Center, Inc to the contrary. This waiver and release nullifies any prior waiver and release signed by me.

5. CONSENT TO MEDICAL TREATMENT
I agree that Restorative Wellness Center, Inc including its affiliated organizations, directors, officers, sponsors, employees, agents, successors, and assigns may, but has no duty to provide me, through medical personnel of their choice, customary medical or training assistance, transportation, and emergency medical services.

I have read this waiver, release and consent and understand that I have given up substantial rights by signing it. I am signing this waiver, release and consent voluntarily.

Your Signature *

Name Parent/Guardian *

First

Last

Date *

Parent/Guardian Signature *

If the person participating in the Activity is not yet 18 years old; As a parent or legal guardian of the above named child, I verify that I fully agree to, understand, and accept all provisions of this Waiver, Release and Consent.

Thank you for private session.

PLEASE FILL OUT FORM BELOW before our appointment.

Personal Health Information

Physical History

Smoking History

Nutrition History

Emotional History

Family History