Retainer intake

Full name of the principal

The individual whose health management is being arranged.

Are you completing this form on behalf of the principal?
—Please choose an option—No, I am the principalYes, I am an assistant or representativeYes, I am a family member

Contact name for this enquiry

Preferred communication method
—Please choose an option—Email onlyWhatsAppPhone callSignal

Languages spoken by the principal

How frequently does the principal travel internationally?
—Please choose an option—Rarely — primarily based in one locationOccasionally — a few times per yearFrequently — multiple countries per month

Current diagnosed conditions

Include everything under active management, however minor it may seem.

Current medications and supplements

Prior surgeries or significant medical interventions

Known allergies

Does the principal currently have a primary physician or specialist team?
—Please choose an option—Yes, an established team is in placePartially — some specialists but no coordinated careNo — this is part of what we need to establish

What is the primary reason for seeking private health management?

A specific treatment, a transformation goal, ongoing complex condition management, or something else entirely.

What does a successful outcome look like in 12 months?

Be specific about what would make this arrangement worthwhile.

What has prevented this from being addressed properly until now?

Are there specialists, facilities, or approaches you want included or excluded?

How long do you anticipate needing ongoing management?
—Please choose an option—3 to 6 months6 to 12 monthsMore than 12 monthsIndefinite — ongoing relationship

When do you need management to begin?
—Please choose an option—ImmediatelyWithin the next monthWithin 1 to 3 monthsNo fixed start date

Are there other individuals involved in decision-making for this case?

Family members, legal representatives, financial advisors — anyone whose involvement affects how we proceed.

Is there anything else Zenify should know before the initial case review?