90-Day Patient Intake – AI Wellness

Personal Information

Full Name

First Name

Last Name

Date of Birth

Phone

Gender

Male

Female

Prefer Not To Say

Address

Street Address

Apartment/Unit Number

City

State/Province

Zip/Postal

Country

Emergency Contact

Name

Relationship

Phone

Health History

Primary Physician Name

Primary Physician Phone

Primary Physician Clinic Name

Current Medications (incl. dosage)

Allergies:

Lifestyle Overview (Sleep, Exercise, Diet, Hydration)

Past Surgeries / Procedures (with dates)

Chronic Conditions / Diagnoses

Remote Patient Monitoring (RPM) — Vital Friend Wearable

Overview:

As part of the 90-Day Pilot, participants may receive a Vital Friend wearable device for continuous monitoring of vital signs and activity. The data collected will help personalize care, enhance early detection, and optimize program outcomes.

4A. Enrollment & Device Assignment

I agree to participate in Remote Patient Monitoring using the Vital Friend wearable.

Device ID / Serial (Clinic Use)

Date Issued

Issued By

Preferred Wearing Style

Wrist

Clip

OtherOther

4B. Data & Sharing Consent (initial each)

I consent to the collection and analysis of biometric data (HR, HRV, SpO₂, temperature, activity, sleep, etc.).
I authorize AI Wellness clinicians and care teams to analyze my data for care optimization.
I authorize my Primary Physician (and their delegates) to receive RPM alerts when relevant.
I consent to de-identified data use for research, performance analytics, and quality improvement.

4C. Connectivity & Responsibilities (initial each)

I will wear and charge my device daily as instructed.
I will maintain Bluetooth or cellular connection for data transmission.
I understand that RPM does not replace emergency care.
I will contact a medical provider or call 911 for any urgent symptoms.
I will return the device in good condition at program completion.

Consents & Agreements

I Consent to:

to AI Wellness collecting, storing, and analyzing my biometric, wellness, and engagement data.
to participation in pilot programs, wearable integration, and app tracking.
AI Wellness does not guarantee specific outcomes.
Terms & Conditions, Refund Policy, Privacy Policy, and Shipping Policy.

Subscription / At-Home Care

Would you like to receive at-home care kits?

Yes

(Skincare, supplements, hair care, meal prep, hydration)

I understand shipments are non-refundable unless canceled due to non-compliance.

Preferred Shipping Address

Frequency

Weekly

Biweekly

Monthly

Practitioner & Brand Participation

Are you a Licensed Practitioner interested in joining our network?

Yes

Are you a Brand Partner interested in collaboration?

Yes

I Consent to

marketing and media exposure as per Terms & Conditions.

Events, Masterclasses & Raffles

I Consent to:

receive invitations to AI Wellness events, masterclasses, and raffles.

Preferred communication:

SMS

Voice AI Call

Voice AI & Automated Follow-Up

I Consent to:

automated AI voice or SMS check-ins for reminders, hydration, and progress updates.

I understand

escalations can be routed to a live representative.

Acknowledgment & Signature

I certify the above information is accurate and complete. I have read and understand all consents, including Vital Friend Remote Patient Monitoring and AI Wellness 90-Day Pilot participation.

Signature (typed in)

Clear

Name (Print)

Date

If you are human, leave this field blank.

AI Wellness Center of Excellence — 90 Day Pilot Patient Intake Form

Personal Information

Emergency Contact

Health History

Remote Patient Monitoring (RPM) — Vital Friend Wearable

Consents & Agreements

Select up to 5 Programs

Subscription / At-Home Care

Practitioner & Brand Participation

Events, Masterclasses & Raffles

Voice AI & Automated Follow-Up

Acknowledgment & Signature