Client Health Form | Alive Luxury Private

Client Health Information

Congratulations on your booking.

We need your health information to prepare your team immediately.

Please fill out the health form below right now.

1. The form is extensive and all information is required in as much details as possible.

2. Allow up to 1 Hr to complete the form and have a support person help or call us to complete with us over the phone

3. All information is protected by SSL and this NDA Agreement - only the Program Director receives this information.

Health Form

First Name

Last Name

Phone

Start Date

Length of Stay

Emergency Contact

Emergency Contact Phone

Do you have any family/friends/support people attending the program with you?

Yes

Unsure TBA

If yes support people will be required to attend elements of the program (e.g. the same diet will be provided). They will be guided by the program director exactly how to support you and how not to distract treatment. If they wish to attend any elements of the program (e.g. yoga, massage, fitness, adventure, therapy) we need to be advised and a quote provided prior to attending. Please advise belo

Please List All Current Health Care Providers & Their Contact Email and Phone Numbers

Do You Give Alive Permission To Contact Your Health Care Providers Should We Require Clarity For Your Health Treatment?

Please attach any recent health results or tests:

Upload File

Your date of birth:

Current Weight and Height

ALIVE LUXURY PRIVATE RETREAT
Private Retreats For Wellness, Detox, Mental Health & Rehab

Client Health Information

Health Form

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Loving What We Do Since 2009

ALIVE LUXURY PRIVATE RETREAT Private Retreats For Wellness, Detox, Mental Health & Rehab

Client Health Information

Health Form

Loving What We Do Since 2009

ALIVE LUXURY PRIVATE RETREAT
Private Retreats For Wellness, Detox, Mental Health & Rehab