• Patient Information

• Name*
  First Name Last Name
• Date of Birth*
   - Month  - Day Year

  Date
• Email*
  example@example.com
• Phone Number*
  Please enter a valid phone number.
• Emergency Contact Person*
  First Name Last Name
• Emergency Contact Phone Number*
  Please enter a valid phone number.
• How did you hear about us?

• Medical Condition

• Do you have any medical conditions or concerns?*
• Are you currently taking any medications? If yes, please list them below.*
• Do you have any allergies? If yes, please list them below.*
• Do you have any of the following?

  	Yes	Details of Condition
  High Blood Pressure (Hypertension)
  Arrhythmias or Irregular Heart Beats
  Swelling (Edema)
  Lung Disease (Pulmonary)
  Congestive Heart Failure (CHF)
  History of Heart Attack (MI)
  Abnormal EKG
  Kidney Disease
  Anemia
  Asthma
  Bleeding/Clotting Disorder
  Diabetes
  History of Stroke
  History of Anxiety
  Night Sweats
  Sudden Weight Loss
  Skin Disorder
  G6PD Deficiency (Retinal Disease)

• Are you currently pregnant or breastfeeding?*
  Yes No
• Have you recently or are you currently experiencing shortness of breath, chest pain/discomfort?*
  Yes No
• Have you recently or are you currently experiencing swelling (edema)?*
  Yes No
• Have you recently or are you currently experiencing concerns with bleeding?*
  Yes No
• Do you have any concerns you would like ot discuss with the nurse?

• Acknowledgment

• Check all that apply:*
  I understand that IV hydration therapy is not appropriate for some medical conditions. I understand that this procedure cannot guarantee 100% expected results. I understand that several treatments might be needed to achieve good results. I understand Primary Hydration & Wellness reserves the right to refuse to initiate or continue any IV therapy at any time based on the medical professional or staff's discretion. I certify that all information in this form is accurate and true to the best of my knowledge.
• I grant permission to Primary Hydration & Wellness to take photographs or videos for the purpose of advertising and marketing.*
  Yes No
• Your Signature*
  Clear
• Date Signed*
   - Month  - Day Year

  Date
• Submit
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