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Your Waiver / Intake Form

Thank you for taking the time to complete this intake form. Your responses help me provide a personalized, supportive, and holistic session. All information is confidential.

First name

Last name

Birthday

Month

Day

Year

Age

Single choice

Male

Female

Email

Phone

Emergency Contacts

Multi choice

Iridology Assessment

Health Coaching Session

Follow-Up Session

Have you ever had an iridology assessment before?

Yes

No

If yes, when and with whom?

Primary Intentions

What are your top 1-3 goals for this session? (Ex: energy, digestion, stress hormones, immune support, Clarity)

What feels the most out of balance in your body?

Current Symptoms & Patterns

Other

Medical Background

Do you have any diagnosed conditions?

Yes

No

Are you currently under medical care?

Yes

No

Are you pregnant, nursing, or trying to conceive?

Yes

No

Medications & Supplements

Please list all prescription medications (name & dosage): Over the counter medications: Supplements / herbs / vitamins:

Lifestyle Snapshot

How would you describe your current stress level?

Low

Moderate

High

Chronic

Sleep quality

Restful

Interrupted

Difficulty falling asleep

Difficulty staying asleep

Movement/physical activity:

Minimal

Gentle

Moderate

High

Nutrition Overview

Any known food sensitivities or allergies?

Foods you crave often:

Nervous System & Emotional Health

What helps you feel calm or regulated?

Additional Information

Is there anything else you’d like me to know about your health, history, or intentions?

How did you hear about us?

Consent, Assumption of Risk & Waiver

I understand iridology and health coaching are complementary wellness services, not medical care, and do not diagnose, treat, cure, or prevent disease. I am responsible for my health decisions and will consult my licensed healthcare provider for medical concerns. I voluntarily assume all risks and, to the fullest extent permitted by law, waive and release Glow & Grow with D LLC (including its owners, employees, contractors, and representatives) from liability related to the services, except where prohibited by law.

Client Conduct & Boundaries Acknowledgment

I understand these services are strictly professional. Unwanted personal, romantic, sexual, or inappropriate comments or advances are not permitted. If my behavior violates professional boundaries or makes the provider feel unsafe or uncomfortable, services may be refused or ended immediately.

Signature

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Thank you for trusting me with your wellness journey. I look forward to supporting you.