Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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?
Rows
Yes
Details of Condition
High Blood Pressure (Hypertension)
1
Arrhythmias or Irregular Heart Beats
2
Swelling (Edema)
3
Lung Disease (Pulmonary)
4
Congestive Heart Failure (CHF)
5
History of Heart Attack (MI)
6
Abnormal EKG
7
Kidney Disease
8
Anemia
9
Asthma
10
Bleeding/Clotting Disorder
11
Diabetes
12
History of Stroke
13
History of Anxiety
14
Night Sweats
15
Sudden Weight Loss
16
Skin Disorder
17
G6PD Deficiency (Retinal Disease)
18
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
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: