HSA Eligibility Client Intake Form – Vitalux Med Spa

Ready to Book Your Visit? If you're using your HSA or FSA, please complete this form and bring it to your appointment or email it to vitaluxmedspa@gmail.com prior to your visit. To schedule, book online and select an HSA-eligible service, or call us at (860) 707-5402. Our team will guide you through next steps to ensure your treatment qualifies for tax-free payment benefits.

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Section 1: Client Information (Please type below your)

Full Name: 
Date of Birth: 
Phone Number: 
Email Address:

*

Section 2: Medical History

Are you currently being treated for any of the following conditions? (Check all that apply):

*
Required
Briefly describe your symptoms or medical concerns: *
Have you been formally diagnosed with any condition above by a licensed healthcare provider? 
Yes or No
If yes, please list diagnosis and date:
 *
Are you currently under the care of a physician or medical provider for this issue?
Yes or No
 *
Are you taking any prescribed medications or treatments for this condition?
Yes or No. 
If yes, please list the medications
 *

Section 3: Treatment Goals & Preferences

Which treatment(s) are you seeking to use your HSA/FSA for? (Check all that apply): *
Required
What results are you hoping to achieve from this treatment? *

Section 4: Authorization & Acknowledgment

I understand that HSA/FSA coverage is based on medical necessity and proper documentation. I confirm the information provided above is accurate to the best of my knowledge. I consent to the clinical evaluation and, if applicable, request a Letter of Medical Necessity from a licensed provider at Vitalux Med Spa.

By typing my name below, I acknowledge that the information I have provided is accurate and complete. I understand that this typed name will serve as my legal signature for the purposes of this form.

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Today's Date *
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Provider Use Only:

Diagnosis (ICD-10): 

 *
Treatment Plan Approved:  *
Provider Name & Signature:  *
*
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