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Client Intake Form

First name

Last name

Phone

Address

Emergency Contact and Phone Number

Please list all of your medical conditions & preferences

I authorize Warriors for Wellness to use the following to post online or print for its business and social media platforms:

Testimonials

Photograph

Video Recording

I have reviewed the Authorization for Release of Health Information and Required Notice, and Full Disclaimer and Release of Liability Policies and understand and consent to these stated policies.

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I have read, understand, and accept the Warriors 4 Wellness Website & Social Media Policies/Terms & Conditions

I have read, understand, and accept the terms & conditions of the Group and Individual Service Agreement/Informed Consent

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided. I also confirm that I have read and fully understand the above Authorizations/Policies/Terms/Conditions, & Service Agreements, and am in complete agreement thereto, and do freely and without duress sign and consent to all terms contained therein:

Signature

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