Intake Form

Date

Name

DOB

Age

Address

City

State

Zipcode

Phone

Email

Reason for visit:

Emergency Contact Name

Emergency Contact Phone

Please briefly describe why you are seeking IV infusion or injection therapy? For example: Are you looking to improve your energy, skin/hair/nail quality, recovery times, immune system, or hydration status? Are you seeking treatment for a hangover or looking to feel and look better?

Allergies (Medications, foods, etc.): Specially Sulfa

Current Medications: (Please include OTC & supplements)

Please select any conditions that apply to you:

Cardiovascular and Respiratory

Gastrointestinal and Urinary

Metabolic/Endocrine/Autoimmune

Neurologic

Stroke/TIA

Parkinson's

Seizures - date of last seizureSeizures - date of last seizure

Multiple Sclerosis

Alzheimer's

Hematology

Anemia (Iron Deficiency, Pernicious,Aplastic, Hemolytic, Sickle Cell)

MTHFR

G6PD Deficiency

Muscuskeletal

Psychological

Depression

Anxiety or Panic Attacks

Cancer

Location of cancerLocation of cancer

Chemotherapy

Radiation

Women (non-menopausal)

Last Menstrual PeriodLast Menstrual Period

Are you currently breastfeeding?Are you currently breastfeeding?

Any chance you are pregnant?Any chance you are pregnant?

Pain

CRPS

Fibromyalgia

Do you drink alcohol or abuse any types of drugs? If so, please explain:

Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?

Would you like to tell us anything else that you feel like is important?

I attest that the information I have provided is true and accurate to the best of my knowledge:

Signature

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Date

Type name

Intake Questionnaire