Health and Safety Client Intake Form

Personal Information:

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

Region

Postcode

Country

Phone Number

Email Address

Emergency Contact:

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to you

Medical History:

Please check any conditions or provide details as applicable

Allergies

please specify

Asthma or breathing difficulties

High blood pressure

Low blood pressure

Heart condition

Recent surgery or injury

please specify

Skin conditions or sensitivities

please specify

Medications currently taking

please specify

Other medical conditions

please specify

Any adverse effects to extreme temperatures (hot or cold)

please specify

Recovery Clinic Services:

Please indicate if you are interested in or plan to use any of the following services

Experience and Preferences

Have you used any of these services before?

Yes

Acknowledgment and Consent:

I acknowledge that I have read and understood the information about the services offered in the recovery clinic. I am aware that these services may involve exposure to temperature variations and physical sensations. I have provided accurate information about my health and medical history to the best of my knowledge.

I understand that the recovery clinic staff is not responsible for any adverse reactions or injuries resulting from the services, provided that they are administered in accordance with the guidelines and recommendations of the facility. I consent to receive these services and assume any associated risks.

I have read and agree to the Acknowledgment and Consent

Date

Please customize this intake form to align with the specific services and requirements of your recovery clinic. Ensure that you have a process for securely storing and maintaining client records in accordance with relevant privacy laws and regulations. Additionally, consider consulting with legal counsel or a healthcare professional to ensure your client intake form complies with applicable laws and best practices.