GENERAL PATIENT INTAKE FORM

Location:

AI Wellness Center of Excellence

2080 Century Park East • Suites 707 & 1204 • Los Angeles, CA 90067

GENERAL PATIENT INTAKE FORM

PERSONAL INFORMATION

Full Name
Full Name
Address
Address
Street Address
Apartment / Unit Number
City
State/Province
Zip/Postal

REASON FOR VISIT / TREATMENT INTERESTS

REASON FOR VISIT / TREATMENT INTERESTS

MEDICAL HISTORY

MEDICAL HISTORY
Are you under a physician’s care?

TREATMENT SAFETY SCREENING

(To determine eligibility for services)
Please indicate if you have any of the following:
If checked, certain services may require modification or may not be appropriate.

LIFESTYLE SNAPSHOT

Helps personalize your treatment experience.
Sleep Quality:
Stress Levels:
Daily Activity Level:
Hydration (per day):

MEDIA, FILMING & PHOTO CONSENT

Please select one:

AI WELLNESS CONNECT APP CONSENT

The AI Wellness Connect App supports check-ins, digital forms, and treatment history.
App Download & Use
Digital Profile Creation
Automated Communications
Data Storage

LIABILITY RELEASE & SERVICE CONSENT

I understand and agree that:

  • AI Wellness services are non-medical, elective wellness treatments.
  • They do not diagnose, cure, or prevent any disease.
  • Treatments may involve heat, light, EMS, laser, shockwave, detox, or physical stimulation.
  • I must disclose all medical conditions accurately.
  • Staff may adjust or stop treatment for safety.
  • Results vary; no outcomes are guaranteed.
  • I voluntarily assume all risks associated with services received.
  • AI Wellness is not responsible for:
     – reactions due to undisclosed conditions
     – discomfort or side effects
     – unmet expectations
     – failure to follow instructions

I voluntarily consent to receive services at the AI Wellness Center of Excellence.

HIPAA & PRIVACY ACKNOWLEDGMENT

I acknowledge that:

  • AI Wellness follows HIPAA guidelines for patient privacy.
  • My information will be used only for treatment, scheduling, and internal operations.

My data is securely stored and never sold.

PAYMENT & CANCELLATION POLICY

I understand that:

  • All services are elective and non-refundable once rendered.
  • Cancellations within 24 hours may incur a fee.

Packages, memberships, and credits are non-refundable.

SIGNATURES