IV (Intravenous) Therapy Intake Form
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
What is the motivation behind your interest in receiving IV Therapy?
Have you received IV Therapy before?
What was your experience like?
Can you provide a list of health conditions or medical concerns to be evaluated for the potential benefits of IV Therapy?
Low Depressed Mood
Trying to get Pregnant/Fertility Prep
Numbness/Tingling of the body
Please check if you have any of the diagnoses below
High Blood Pressure
Low Blood Pressure
MI / Heart Attack
Congestive Heart Failure
Sudden Weight Loss
Date of last Physical Exam/Blood Test
Results of the test
Provide a list of all known and suspected allergies
Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries
Please provide a comprehensive list of all the prescription drugs and supplements you are presently taking, including their respective doses.
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
More than half the days
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
How did you hear about us?
Should be Empty: