Registration Form

Registration Form

IV Hydration
Date of Service*

MonthDayYear
Date
Gender Identification*
Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Date
Address*

Street Address

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Postal / Zip Code
Phone Number*
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Email*
example@example.com
Emergency Contact Name*
Emergency Contact Number*
How did you hear about us?*
If "Other" selected, please indicate here.
Please check if you've had or have any of the following medical history?*

Congestive Heart FailureSevere Renal ImpairmentSodium Retention or Electrolyte ImbalanceHigh/Low Blood PressureSevere Frequent HeadachesFainting/Seizures/EpilepsyDiabetes/Low Blood SugarAny Liver Condition (e.g. Liver Cirrhosis, Liver Disease)None / No Known Condition(s)Other
Please check if you've had or have any of the following allergies.*

SulfaSaline SolutionNut AllergyNo Known AllergiesOther
If you checked any of the above boxes or have any other condition not listed, please list here. If none of the above applies, enter N/A.*
To help us see where we can make your life better, please check the following that are troublesome and/or persist over time. Please check all that apply.*

Low EnergyFatigue/Burn out feelingWeight GainThinning hairDepression/AnxietyFoggy Brain/Memory LapseBreast TendernessWater RententionVaginal DrynessErectile performanceDifficulty with orgasmHeavy or irregular cycleMenopause/ Post-MP BleedingCrampsFibrocystic BreastsHistory of Thyroid issuesIncreased urinary urgeDifficulty SleepingExercise IntolerancePoor concentrationLoose or sagging skinBloating after mealsSugar cravingsConstipationUpset stomachHistory of ulcerSkin ConditionNone / No Known Condition(s)Other
If you checked any of the above boxes or have any other condition not listed, please list here. If none of the above applies, enter N/A.*
Please list your history of any major surgeries and hospitalizations. If none of the above applies, enter N/A.*
Please list all prescription drugs, over-the-counter (OTC) medications and vitamins that you are taking? If none of the above applies, enter N/A.*
What treatments are you doing or have you done to make you look and feel better? If none of the above applies, enter N/A.*
Do you currently take daily B12, B complex, and /or Vitamin D? If so, please list below. If none of the above applies, enter N/A.*
Initials required for acknowledgement:
Patients with kidney and active liver disease should be treated with extreme caution.blanks*
Patients with congestive heart failure or end stage renal disease have potential for serious harm from receiving fluids. blank*
Covid Questionnaire. Have you experienced any of the following symptoms in the last 48 hours?*

FeverCoughShortness of breathBody acheSore throatDiarrheaLoss of taste and smellTested positive for covid in the last 10 daysNone of the above
Terms, Conditions & Consent for IV Hydration Therapy

Our hydration therapy is specifically designed to counteract symptoms of dehydration, fatigue, and the residual effects of nutrients and H2O depletion. We offer no diagnostic testing, make no medical diagnoses, and reserve the right to refuse treatment to any patients we deem are intoxicated unstable, or whose symptoms are not consistent with the above. The vast majority of our clients receiving our therapy feel greatly improved; however, every individual is different and there is no guarantee that you will feel better after an infusion; nor does your improvement of symptoms exclude other coexisting potential medical conditions. This document is designed to serve as confirmation of informed consent for IV therapy as suggested by the qualified staff present at the current location. I have informed the staff of any known allergies to drugs or other substances, or of any past

I have informed the staff of all current medications and supplements I am taking. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and give my concerns.

The procedure involves inserting a needle into a vein and injecting the selected solution. Risks of intravenous therapy include, but are not limited to: discomfort, bruising, and pain at the site of injection. Other rare but possible side effects include but are not limited to: inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Nutrients are forced into the cells by means of a high concentration ingredient. I understand the information provided on this form and agree to the foregoing.

By signing, I acknowledge that I have received all the information and explanation I desire concerning the procedure; and, that I authorize and consent to the performance of the procedures(s).
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