New Client Intake Form

I acknowledge my informed consent to receive services that will be provided by Renewal Care, LLC (hereafter referred to as Renewal). I hereby release Renewal, and their staff, associated health professionals, affiliates, and agents from claims and liabilities arising from the use of mild hyperbaric therapy, Life Vessel (relaxation therapy), pulsed electromagnetic field therapy, whole body vibration, and other wellness treatment modalities. I hereby grant permission to Renewal to provide me with mild hyperbaric therapy, Life Vessel (relaxation therapy), pulsed electromagnetic field therapy, whole body vibration, and other wellness treatment modalities. I also acknowledge that Renewal does not claim to prevent, treat, nor cure any condition or provide care, diagnosis, or rehabilitation to individuals, nor do they or their staff, associated health professionals, affiliates, and agents apply medical, mental health or human development principles, but rather provide wellness services including, mild hyperbaric therapy, Life Vessel (relaxation therapy), pulsed electromagnetic field therapy, whole body vibration, and other therapeutic modalities, that may benefit me. I understand that Renewal and their staff, affiliates, and agents are not health care providers and services are not offered in a health care setting. I have read, fully understand, and consent to any services provided. I have also completed the health questionnaire to the best of my ability, which accompanies this consent form. I agree to hold Renewal or their staff, associated health professionals, affiliates, and agents harmless from any blame or issues regarding services provided by Renewal.

I will inform Renewal and any staff, associated health professionals, affiliates, or agents of any change in my medical condition and/or diagnosis before utilizing services provided by Renewal.

Although services offered by Renewal have been reported to be beneficial for a wide range of conditions, an outcome of prevention or cure cannot and will not be guaranteed. I understand that Renewal does not, in any way, recommend its services and offered therapies as a substitute for any medical treatments prescribed by my physician.

I authorize Renewal to send me email and text notifications to keep me informed of new bookings, changes to my bookings, new equipment, special offers and membership deals, changes in opening or holiday hours, events, and reminders for upcoming appointments. I understand that I can opt-out of email and/or text notifications at any time.

I authorize Renewal and its staff, or associated health professionals, to collect my personal and medical information as documented above. In addition, I authorize Renewal and its staff, or associated health professionals, to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will not be disclosed to unaffiliated third parties without my permission. I have completed the health questionnaire, which accompanies this consent form, truthfully and to the best of my ability. I agree to hold Renewal and any staff, associated health professionals, affiliates, or agents harmless from any blame or issues regarding services provided by Renewal.

I have reviewed service and package pricing on the www.renewal.care website and/or reviewed pricing with a Renewal Care Wellness Center staff member.

Your appointment time is reserved just for you. Our goal is to provide quality services to all our clients in a timely manner and in a low-stress environment. No-shows, late arrivals, and cancellations inconvenience not only our staff, but our other clients as well. A last-minute, late cancellation, or missed appointment leaves a hole in the service provider’s day that could have been filled by another client. If cancellation is necessary, we require that you contact us with at least a 24-hour notice (1 business day) in advance for any cancellations or changes to your appointment (your prior notice will allow another client to access to that available appointment time). Clients who provide less than a 24-hour cancellation notice, or miss their appointment altogether as a no-show, will be charged a non-refundable late cancellation/missed appointment fee of $50.00.

If you need to reschedule or cancel your appointment, please call us at (503) 724-1212 within operating business hours to reach us directly. You may also leave a detailed voicemail message anytime or email [email protected], preferably with “Reschedule” or “Cancel” in the subject line. We will return your call or email as soon as possible. You can also reschedule or cancel your appointment using the online customer portal, with the email address that was used for appointment booking, on the www.renewal.care website up to 24 hours before your appointment start time.

We are asking you to arrive early or on time so that we can keep our schedule for clients scheduled after you. Should you be late, your scheduled service session may be cut short.

Client payment due for services rendered is expected at the time of service. We accept cash payment and all major credit cards.

I understand that by filling out and signing this Intake Form, I shall be the party responsible for the payment of fees and any other charges payable to Renewal. I understand that I must notify Renewal of address, phone, email, or payment changes in a timely manner.

Once your booked service begins (is performed) we do not offer any type of refunds. We expect you to book services based upon your trust from research about Renewal’s service offerings. If you are uncertain about the services and therapeutic modalities offered, we encourage you to do your due diligence prior to booking. During your outreach and initial consultation with us, we encourage you to ask any questions you may have prior to rendering your booked services.

I do affirm that the statements I have made in this document are true to the best of my knowledge and belief.