CLIENT INTAKE FORM & CONSENT TO TREAT

CLIENT INTAKE FORM & CONSENT TO TREAT

Vytality Blu Health & Medspa

Client Information

**Please answer the question below

Please mark any of the following conditions you may currently have.

*Informed consent: Patients acknowledge the risks of the procedure, including injury, infection, and death, and agree to the treatment.

*Medical advice: Providers may state that they are not giving medical advice or making claims about curing diseases.

*Disclosure: Patients are required to disclose current medications and medical conditions.

*Liability: Patients may agree to indemnify the provider from claims arising from their use of services.

*Electronic communications: Patients may consent to receiving communications from the provider electronically.

*Confidentiality: Patients may have the right to request that their medical information be communicated in a certain way.

*The information contained herein is not intended to diagnose, treat, cure, or prevent any disease.

*The services provided have not been evaluated by the Food & Drug Administration.

*It is recommended you consult you health care provider prior to starting any new medical treatments.

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