Patient Intake Form

General Medical Intake & Patient Consent

Plain-Language Summary

This document serves as your patient intake form and full informed consent. By signing, you confirm that you:

Consent to evaluation and treatment by Biomolecular clinical staff.
Have accurately disclosed your medical history, medications, allergies, and relevant health information.
Understand the nature, risks, and limitations of the services you are receiving.
Agree that Biomolecular is not your primary care provider.
Consent to the collection and lawful use of your health information under HIPAA.
Acknowledge that certain services require medical clearance before participation.
Agree to resolve disputes through binding arbitration.
Have had the opportunity to ask questions and received satisfactory answers.

Please read every section. If anything is unclear, ask a staff member before signing.

1. Visit Details & Basic Info

Which location are you visiting? *

Date of Visit *

Sex *

Female Male

First Name *

Last Name *

Height

Weight (lbs)

Date of Birth *

2. Communication Preferences

Phone * * Best Number To Contact You For Your Appointment

E-mail * * Must Be Valid Email To Receive Medical Records

Email/SMS Opt-In

Transactional – Appointment confirmations, receipts, and account notifications.

Email SMS

Marketing – Promotional offers, newsletters, and campaign messages.

Email SMS

By checking this box, I agree to receive Customer Care and Account Notification SMS messages from at the number provided. Consent is not required to receive services. Message frequency may vary. Reply HELP for assistance or STOP to opt-out at any time. Mobile opt-in data will not be shared with third parties.

3. Address

Street Address *

Address Line 2

Country *

State *

* 1st Select Country

City *

* First Select State

Zip *

4. Emergency Contact

First Name *

Last Name *

Emergency Phone *

5. What are your primary health optimization goals?

Optimize lifestyle Hormone Health Brain Health Gut Health Biohacking Manage family medical risk Heart Health Longevity (extending healthspan)

⚠️ Age Requirement: You must be at least 18 years old to receive certain technology services, and at least 18 years old for testing, medical services, and procedures. If you are 70 years of age or older, a Health provider Good Faith Exam (GFE) is required for all wellness services before any services may be rendered.

⚠️ If you are signing this form as a Legally Authorized Representative on behalf of an adult patient who is unable to consent for themselves, you must also complete and sign the Health Legally Authorized Representative Consent & Attestation form separately.

Do you have any allergies to medications? *

Yes No Known Drug Allergies

Do you confirm all statements above are true and complete? *

Yes No

Are you interested in our *

Yes No

8. Consent Acknowledgement

Patient has read and accepted the terms of Consent & Waiver section of this General Medical Intake Form. * Patient has, to the best of Patient's knowledge, honestly and accurately answered all medical intake questions included in this form. *

Signature *

Sign above

Date