Optimal You Wellness | Chronic Care & Preventative Health

Personal Information

Client Name

Date

Phone Number

Address

Date of Birth

Emergency Contact Name

Relationship

Preferred Payment Method

MTN MoMo

Vodafone Cash

Card

Gender

Male

Female

Other

1. Health & Medical Information

Current Weight (kg)

Height (cm)

Weight Goal

Lose Weight

Maintain Weight

Gain Muscle

Are you taking any medications or supplements?

Yes

4. Medical & Surgical History

Tell us your surgical history

2. Dietary Habits & Food Preferences

Foods You Avoid (Due to allergies, culture, or preference)

How often do you eat out?

Rarely

1-2x per week

3+ times per week

Favorite Meals

Least Favorite Foods

3. Hydration & Lifestyle

4. Wellness Goals & Preferences

Have you followed a diet or meal plan before?

Yes

5. Additional Notes & Special Requests

Do you have any specific health concerns or questions?

How can we best support you in reaching your goals?

6. Chronic Care Subscription Agreement

Select a Care Plan

Hypertension Plan

Includes doctor consultation, nurse monitoring, and lifestyle counseling.

Diabetes Plan

Includes sugar monitoring, diet adjustments, and regular check-ups.

Cardiometabolic Plan

Comprehensive heart and metabolic health management.

Executive Annual Plan

Full-year coverage with priority access and comprehensive screenings.

What the Plan Includes:

Scheduled doctor consultation
Nurse follow-up monitoring
Care plan adjustments
Lifestyle counseling

Payment Policy:

Monthly Subscription applies
Payment due before service delivery
E-payments only (No cash)
No insurance billing
Non-transferable

Refund & Cancellation:

Fees are non-refundable once services are rendered.
Written notice required 14 days before renewal cycle for cancellation.

7. Consent & Agreement

I consent to evaluation, management, and monitoring by Optimal You Wellness Clinic.

I agree to the Chronic Care Subscription Agreement terms and policies listed above.

I acknowledge I have been informed of the Clinic Policy Manual regarding payment, patient flow, and staff conduct.

Digital Signature (Type Full Name)

Date

Personal Information

Client Name

Date

Phone Number

Address

Date of Birth

Emergency Contact Name

Relationship

Preferred Payment Method

MTN MoMo

Vodafone Cash

Card

Gender

Male

Female

Other

1. Health & Medical Information

Current Weight (kg)

Height (cm)

Weight Goal

Lose Weight

Maintain Weight

Gain Muscle

Are you taking any medications or supplements?

Yes

4. Medical & Surgical History

Tell us your surgical history

2. Dietary Habits & Food Preferences

Foods You Avoid (Due to allergies, culture, or preference)

How often do you eat out?

Rarely

1-2x per week

3+ times per week

Favorite Meals

Least Favorite Foods

3. Hydration & Lifestyle

4. Wellness Goals & Preferences

Have you followed a diet or meal plan before?

Yes

5. Additional Notes & Special Requests

Do you have any specific health concerns or questions?

How can we best support you in reaching your goals?

6. Chronic Care Subscription Agreement

Select a Care Plan

Hypertension Plan

Includes doctor consultation, nurse monitoring, and lifestyle counseling.

Diabetes Plan

Includes sugar monitoring, diet adjustments, and regular check-ups.

Cardiometabolic Plan

Comprehensive heart and metabolic health management.

Executive Annual Plan

Full-year coverage with priority access and comprehensive screenings.

What the Plan Includes:

Scheduled doctor consultation
Nurse follow-up monitoring
Care plan adjustments
Lifestyle counseling

Payment Policy:

Monthly Subscription applies
Payment due before service delivery
E-payments only (No cash)
No insurance billing
Non-transferable

Refund & Cancellation:

Fees are non-refundable once services are rendered.
Written notice required 14 days before renewal cycle for cancellation.

7. Consent & Agreement

I consent to evaluation, management, and monitoring by Optimal You Wellness Clinic.

I agree to the Chronic Care Subscription Agreement terms and policies listed above.

I acknowledge I have been informed of the Clinic Policy Manual regarding payment, patient flow, and staff conduct.

Digital Signature (Type Full Name)

Date