Medical intake form

Please complete this form before your appointment so our clinical team can review your health history and personalize your visit. It takes about 5 minutes.

Patient information

First name *

Last name *

Date of birth *

Legal sex *

Email *

Mobile phone *

Street address

City

State

ZIP

Emergency contact

Full name *

Relationship *

Phone *

Medications & allergies

Current medications & supplements *

Include prescription, over-the-counter, vitamins, and dosages.

Known allergies

Other allergies & reactions

Describe the reaction (rash, anaphylaxis, GI, etc.).

Today's visit

Help us tailor your Reset Lounge experience.

Primary goal for today's visit *

Consent & acknowledgment

I certify that the information provided is accurate to the best of my knowledge. I understand that Reset Lounge services are elective wellness therapies and are not a substitute for medical care from a licensed physician. I authorize the Reset Lounge clinical team to administer the therapies discussed and understand potential risks including bruising, infiltration, allergic reaction, and rare serious events. I agree to disclose any changes to my medical history prior to each visit.

I consent to treatment and acknowledge the risks described above. *I acknowledge receipt of Reset Lounge's HIPAA Privacy Notice. *I'd like to receive appointment reminders and wellness updates from Reset Lounge.

Signature (type full legal name) *

Date *

Your information is transmitted securely and reviewed by licensed clinical staff.