This intake form is designed to collect health information to facilitate your wellness assessment with Healthspan by Design. The information you provide will be used to personalize your consultation and health recommendations.

You are responsible for providing accurate and complete information. Incomplete or inaccurate information may affect the quality of recommendations you receive.

Your personal health information will be handled in accordance with applicable privacy laws, including HIPAA where applicable. By submitting this form, you consent to the collection, use, and storage of your information as described in our Privacy Policy.

Completion of this form and participation in a wellness assessment does not create a doctor-patient relationship unless explicitly established through separate agreement and in compliance with state medical board regulations.

The recommendations provided are based on the information you provide and general wellness principles. They should not be considered personalized medical advice for the diagnosis, treatment, or prevention of disease. Always consult with your licensed healthcare provider before making changes to medications, supplements, or treatment plans.

By submitting this form, you authorize Healthspan by Design to review your health information and discuss it during your consultation. You may revoke this consent at any time in writing.

By checking the box below and submitting this form, you acknowledge that you have read, understood, and agree to this disclaimer.