Health Intake — Dualia

Personal details

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Full name

Phone

Document / ID

Date of birth

Gender

Nationality

Address

Emergency contact name

Emergency phone

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

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?

Allergies

Current medications

Medical conditions

Final notes

Consent and liability waiver

I confirm that the information I have provided is true and complete, and I agree to inform Dualia of any relevant changes to my health. I voluntarily consent to receive the services and treatments offered by Dualia and its team. I understand that these services carry inherent risks, which I accept of my own free will. To the extent permitted by law, I release THE DUALIA HEALTH COLLECTIVE S.R.L., its staff and owners from any liability for injury or harm arising from my voluntary participation.

I have read and accept the consent and liability waiver.

Signature

Intake form

Consent and liability waiver