Intake Form

Name *

Date of Ranch visit *

Mobile Phone

Email *

Medical

Do you have any walking issues or any condition that would impair your ability to walk independently throughout the property on uneven terrain that includes steps and ramps?

Yes

No

Guests are expected to walk on average of 4 miles a day on hilly, uneven terrain that includes winding pathways with ramps and steps. It is important to consider any balance or cognitive issues.

Please describe:

Do you have any medical condition that could be affected by participating in a fitness class or by receiving a spa service/treatment?

Yes

No

Please descibe:

Are you taking any medication for any condition?

Yes

No

Remember to pack 14-days of medication in original bottles with labels.

Please list your medications.

Have you had any injuries within the last year?

Yes

No

Please describe: *

Have you had any surgeries, including cosmetic within the last year?

Yes

No

Please describe: *

Do you have any skin conditions?

Yes

No

Which condition? What causes it to flare? *

Do you have any implants (i.e. pacemaker, joint replacement, etc.)

Yes

No

Please describe:

Are you pregnant?

Yes

No

Please consult with your physician before reserving your stay, especially if you will be in your 3^rd trimester during your visit. Remember, we are located in Mexico and the nearest US hospital is approximately 1½ hours from the property.

Dietary

Do you have any food intolerances, including allergies?

Yes

No

Please check in with our Maitre´d upon arrival to discuss how we can best accommodate your restrictions.

To what? Your reaction? *

Are any of these intolerances/allergies life-threatening?

Yes

No

Please remember to travel with your Epi-Pen.

Please specify:

Do you have any dietary preferences?

Yes

No

Please check in with our Maitre´d upon arrival to discuss how we can best accommodate your restrictions.

Please specify.

Environmental

Do you have any allergies to soaps, fragrances, oils, skin care products, etc.?

Yes

No

Please describe:

Do you have any environmental or insect allergies?

Yes

No

Please specify:

Are any of these allergies life-threatening?

Yes

No

Please be sure to travel with an Epi-Pen.

Please specify:

Additional Information

Is there any additional information in regards to your health or wellness that we need to know about in order to serve you better?

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