Bio Hacking Luxe – Child Genetic Testing & Mental Wellness Intake Form

(Confidential & HIPAA-Protected Health Information). Please complete before your appointment.

Child Information

First Name

Last Name

Phone Number

Parent/Guardian Name(s)

Date of Birth

Age

Sex

Address:

Emergency Contact

Please provide a next of kin's contact to contact incase of any emergencies. Make sure the contact is active.

First Name

Last Name

Email Address

Phone Number

Surgical & Hospitalization History

Current Medications & Supplements

Allergies

No known allergies

Support attention, focus, and learning

Improve emotional balance and resilience

Identify risks for anxiety, depression, or mood disorders

Assess risks for addiction or behavioral concerns

Optimize nutrition and supplementation

Support for weight, growth, or metabolic health

Sleep optimization

Long-term health & prevention insights

Other

Parental/Guardian Informed Consent & Liability Release

1. Nature of Testing – Genetic testing provides insights into health, behavior, and development.

2. Potential Benefits – May include recommendations for nutrition, wellness, and long-term health.

3. Risks & Limitations – Results may reveal sensitive information (including learning or mental health predispositions).

4. Mental Wellness Disclaimer – Insights are not a substitute for therapy, psychiatric care, or medical treatment.

5. No Guarantees – Results vary among individuals. No warranty is implied.

6. Release of Liability – I release Bio Hacking Luxe from liability related to my child’s results or lack thereof.

7. Medical Care Disclaimer – Services are informational only, not a substitute for pediatric care.

HIPAA Privacy Notice Acknowledgment

I acknowledge receipt of Bio Hacking Luxe’s Notice of Privacy Practices. I understand my child’s health information will be kept .

Bio Hacking Luxe – Child Genetic Testing & Mental Wellness Intake Form

Child Information

Emergency Contact

When did symptoms (if any) first begin?

Surgical & Hospitalization History

Current Medications & Supplements

Allergies

Parental/Guardian Informed Consent & Liability Release

HIPAA Privacy Notice Acknowledgment

Parent/Guardian Signature

Date

Printed Name

Relationship to child