Patient Intake Form

Name

First Name

Last Name

Date Of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

In Case Of Emergency, Please Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

What are your mail complaints? Please check all that apply.

Fatigue or low energy

Stress

Poor diet due to busy lifestyle

Brain fog or trouble concentrating

Low mood or depression

Headaches or migraines

Weight gain/difficulty losing weigh

Recent surgical procedure

Recent illness

Cold of flu symptoms

Facial wrinkles/fine lines

Dull or dry skin

Malabsorption issues

Which statement best describes why you’re getting an IV therapy infusion? Please check all that apply.

I want to have more energy and feel better overall.

I want to do everything I can to enhance my weight loss efforts.

I want to prevent myself from getting sick.

I want to slow down the aging process.

I want to feel and look younger.

I want to have smoother, brighter, and more vibrant skin.

I want to cleanse my body of toxins.

I want to recover quickly from a hangover.

I want to recover quickly from my athletic pursuits/illness/surgery.