Client Forms

Client Forms

Please Complete and Submit

Short History Form

Date:
First name:
Last name:
Address 1:
Address 2:
City:
State:
Zip code:
Email address:
Phone Numbers:
DOB:
Sex:
Weight:
Height:
Status:
Occupation:
How Did You Hear About Us?
Do you have any allergies?
If Yes, Please Explain:
Do you currently see a medical doctor for any reason?
If Yes, Please Explain:
Have you had any surgeries?
If Yes, what were they for, and please give dates:
Are you currently taking any prescription medications?
If Yes, Please give name of meds and what it’s prescribed for:
Please list any supplements and/or over the counter medicines that you are taking:
What is your main concern for this consultation?
Type Of Wellness Service/s Requested:

To the best of your knowledge you have fully disclosed all medical conditions and medical history as well as any other conditions that may affect your Wellness Consultation, Clay Foot Baths, Ion Foot Cleanse Detox and/or Body Treatments with Naturel Vitality. By dating and submitting the form above, you agree to this statement.

Please Download,Complete and Print

Long Client History Form For Wellness Evaluations:

Cancellation & Payment Policy:

Liability Form:

Disclaimer Form: