Demographic & Consent Form

Please complete all required fields. Optional demographic information helps us personalize your experience but will not affect your access to strategy services.

Client Information

Required fields are marked with *

Full Name *

Preferred Name

Date of Birth * (MM/DD/YYYY)

Email *

Mobile Phone *

Address *

City *

State *

ZIP *

Demographics

Optional — used to improve personalization and program evaluation; will not affect your care if left blank

Gender Identity

Sex Assigned at Birth

Pronouns

Race / Ethnicity

Preferred Language

Employment Status

Highest Level of Education

Emergency Contact

Name

Relationship

Phone

Health & Medical Basics

Primary Care Provider (PCP) Name / Practice

Current Medications (or upload list)

Known Allergies (medication/food)

Major Medical Conditions (diabetes, heart disease, etc.)

Are you currently pregnant or breastfeeding?

Billing & Consent

Billing & Membership Authorization *

I authorize BioSphere Human Optimization to charge my card monthly for membership fees. I understand membership renews automatically each month and I must provide 90 days written notice to cancel.

Consent to Share Information with Licensed Clinicians *

I consent to BioSphere sharing my demographic and health information with licensed clinicians of BioSphere Physician Partners, PC for the purposes of clinical assessment, lab orders, and prescription management.

Privacy Acknowledgment *

I have read and agree to the Privacy Policy, Terms of Use, and Disclaimer.

Data Use & Research (Optional)

I consent to the use of my de-identified or aggregated data for internal quality improvement and research purposes.

Electronic Signature

By typing your name below and submitting this form, you acknowledge that your electronic signature is valid and binding.

Full Name (Signature) *

Date * (MM/DD/YYYY)