Intake form

Fill in your details and health history before your visit. Your information is confidential.

By submitting you accept our privacy policy

Full name

Phone

Document / ID

Date of birth

Emergency contact

Emergency phone

Your intention

Tell us what you're looking for — it helps us personalize your visit.

How would you like to feel?

Increase energy and vitalityFeel clear, focused, and mentally sharpFeel calm, grounded, and emotionally balancedImprove sleep and deep restEnhance physical performance and recoverySupport long-term health and longevityOptimize overall wellness and daily functionPrepare for or recover from travel, events, or stressSimply maintain and support my well-being

What are you currently experiencing?

Low energy, fatigue, or burnoutStress, anxiety, or feeling overwhelmedPoor sleep or insomniaBrain fog or lack of focusMood swings or emotional imbalanceFeeling disconnected or “off”Muscle soreness, tension, or injury recoveryCirculation or lymphatic support needsInflammation or immune challengesDigestive or gut health issuesHormonal imbalances (including PMS, menopause, libido)Detox support (lifestyle, alcohol, environmental)Blood sugar or metabolic concernsSkin, bloating, or body composition concernsPost-illness, travel, or stress recovery

Services you're interested in

Bath House Experience (Sauna & Cold Plunges)IV TherapyHormonal Replacement TherapyPeptide TherapyUmbilical Stem Cell TherapyFunctional Medicine ConsultationMassage / BodyworkAcupunctureChiropractic CareInhalation Hydrogen TherapyCompression Boot TherapyNursing Consultation / Treatment

Health screening

Let us know if any apply to you. This protects your safety during treatments.

Pregnant or breastfeeding?

Heart condition?

Kidney condition?

On blood thinners?

Diabetes?

Recent surgery?

G6PD deficiency?

Allergies

Current medications

Medical conditions

Final notes

Consent and liability waiver

I declare that the information provided is true and complete. I understand that Dualia's services are complementary and do not replace professional medical care. I participate voluntarily and assume the inherent risks. (Preliminary legal text — to be confirmed by legal counsel in Costa Rica.)

I have read and accept the consent and liability waiver.

Signature

THE DUALIA HEALTH COLLECTIVE · Dominical, Costa Rica