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Redefining Wellness, Longevity, and Peak Performance
Client Intake Form
About Us
Hypervida
Begin Your Private Wellness Assessment
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
How did you hear about Hypervida?
Google
Referral
Social Media
Medical Provider
Event / Influencer
Other
Which best describe you?
Executive / Entrepreneur
Athlete / Fitness Enthusiast
Biohacker / Longevity Focused
Aesthetic / Anti-Aging Focused
Medical Recovery Client
High-Stress Professional
Couple Seeking Shared Wellness
Select All
Primary goal over the next 90 days:
Increase Energy
Improve Recovery
Enhanced Cognitive Performance
Reduce Inflammation
Improve Skin Health
Hormone Optimization
Preventative Longevity
Stress Regulation
Hours of sleep per night?
<5
5-6
7-8
8+
Other
How many days per week do you train?
0
1-2
3-4
5+
Other
Which Private Wellness Services Interest You?
Hyperbaric Oxygen Therapy (2.0 ATA Multiplace Chamber)
Red Light Therapy (Full Body LED Pod)
EMS Training
IV Drip Therapy / Vitamin Boost
Hormone Testing & Therapy
Peptide Therapy
NAD+ Brain Boost
Microcirculation Therapy
Vitamin D Light Therapy
Membership Access
Intro Offer
Buddy Pass
Date Night Experience
Are you interested in:
Single Sessions
Package Bundles
Membership Options
Concierge Medical Optimization
Current Medications
Have you ever experienced:
Lung Conditions
Ear pressure issues during flights
Pacemaker or implanted device
Cancer history
Pregnancy
Recent surgery (6 months)
Blood clotting disorders
None
Are you under physician supervision?
Yes
No
Finalize Your Wellness Path
(Required)
What would “optimal health” look like for you?
