IV THERAPY INTAKE FORM Name * First Name Last Name Email Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * How did you hear about us? Medical History Please select any relevent health details below: Adrenal gland issue Asthma Anemia Autoimmune condition Blood disorder Cancer Diabetes Digestive/Pancreas issues COPD/Emphysema Epilepsy/Seizures Gout/Arthritis G6PD deficiency Heart condition/CHF Hepatitis High blood pressure HIV/AIDS High cholesterol Endocarditis Infectious mononucleosis Kidney disease Liver disease Low blood pressure/fainting Parathyroid issues Phlebitis Respiratory condition Rheumatic fever Stroke Stomach ulcers Thyroid condition Varicose veins If you checked YES for any condition above, please provide as many details as possible: Allergies * Do you have any allergies or adverse reactions to any of the following medications: No Known Drug Allergies 0.9% Sodium Chloride Lactated Ringers Solution B Vitamins B12 Calcium Magnesium Potassium Vitamin C Zinc Ketorolac/Toradol Ondansetron/Zofran Benadryl Lidocaine Latex Dexamethasone Triamcinalone/Kenalog Medications Please list any medications you take currently, including supplements and aspirin. Are you currently taking blood thinners? No Yes If you answered yes to the question above, please explain: Are you currently breastfeeding, pregnant or trying to get pregnant? N/A No Yes Have you received IV therapy before? No Yes Do you have a phobia of needles? No Yes What is your reason for seeking IV therapy today? By checking the box below, I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the nurse of any changes to my medical history. I agree to waive all liabilities of the nurse or employer for any injury or damages incurred due to misrepresentation of my health history. I agree Thank you!
