Intravenous Therapy Intake Form

Intravenous Therapy Intake Form

Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age:*
Sex*

MaleFemale
Occupation
How did you hear about our office?
In case of emergency, please contact:
Name*
Phone Number*
Please enter a valid phone number.
What are your main complaints?*

FatigueStressPoor diet due to busy lifestyleBrain fog or trouble concentratingLow mood or depressionCold or flu symptomsFacial wrinkles or fine linesDull or dry skinMalabsorption issuesOther
If 'Other', please explain
Which statement best describes why you are here today?*

I want to do everything I can to nourish my bodyI want to do everything I can to enhance my weight loss effortsI want to prevent getting sickI want to recover quickly from my surgery or illnessI want to slow the aging processI want to feel and look youngerI want to have smoother, brighter, and more vibrant skinI want to cleanse my body of toxinsI want to recover quickly from a hangoverOther
If 'Other', please explain:
Medical History
Tell us about your past health:*

Lower back painLeg or Foot pain/NumbnessSpinal StenosisSpinal ArthritisSciaticaNeck PainHerniated DiscDiabetesHand problemsNeuropathyLeg problemsHigh CholesterolKnee surgery/replacementShoulder surgery/replacementSpinal surgeryPlantar FascitisTendonitisBursitisHeadaches/MigranesOther
Are you pregnant or breastfeeding?*

YesNo
Date of last chemistry screen or another lab testing

MonthDayYear
Date
Have you ever been told that you have an electrolyte imbalance or other abnormal labs?*

Hypermagnesemia (high magnesium levels)Hypercalcemia (high calcium levels)Hypokalemia (low potassium levels)Hemochromatosis (high iron levels)Other
Are you diabetic?*

YesNo
Are you a smoker?*

YesNo
If yes, how much do you smoke?
Length of time:
How many alcoholic drinks do you consume in a week?
Do you use any recreational drugs?

YesNo
If yes, which ones and how often?
Please list everything you are currently taking (prescription medications. strength, frequency)
Over the counter drugs (strength, frequency)
Vitamins and Other supplements (strength, frequency)
Do you have any medication or food allergies?*

YesNo
If yes, please list:
Do you have any of the following conditions?*

Blood pressure problemsHeart problemsStroke or "mini stroke"Kidney problemsKidney stonesAsthmaAllergiesSickle Cell AnemiaG6OD deficiencySarcoidosisParathyroid problems (high levels)
List any other medical conditions you have not mentioned above:
List of all surgical procedures you've had with approximate dates;
Is there anything else you would like our medical team to know?
Informed consent for treatment/diagnostic Testing

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.
Date*

MonthDayYear
Date
Signature*

Clear
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Name and Date of Birth of Primary Account Holder
Insurance Card (front)

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Insurance Card (back)

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Release of Information:

This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.
Date

MonthDayYear
Date
Signature*

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Intravenous Therapy Intake Form

Patient Information

In case of emergency, please contact:

Medical History

Insurance Information