IV Therapy Intake Form Patient Name(Required) Cell Phone(Required)Address(Required)Email(Required) Age(Required)Date of Birth(Required) MM slash DD slash YYYY Pronouns(Required) Emergency Contact(Required) Phone(Required)Relationship(Required) How did you hear about us or whom may we thank for referring you?(Required)What is your primary health concern(Required)What IV treatment are you interested in?(Required) Wellness Glutathione Iron High Dose Vitamin C Other Other Have you received IV therapy in the past(Required) Yes No Any complications from blood draws or IVs?(Required) Yes No Yes Are you currently under the care of a physician? (If yes, whom and for what are you being treated for?)(Required) Yes No Yes When was your last blood work completed? CBC (Date) MM slash DD slash YYYY CMP (Date) MM slash DD slash YYYY Iron Panel (Date) MM slash DD slash YYYY **Please attach results when applicable. Drop files here or Select files Max. file size: 32 MB. Do you have a history of any of the following? If yes, please explain.Heart disease Kidney disease Liver disease Low blood pressure Syncope Anaphylaxis Please list any current prescriptions, supplements or over the counter medications you are currently taking:ListMedication or SupplementFor?Dose Add RemoveEmailThis field is for validation purposes and should be left unchanged.
