IV&IM Therapy Intake Form

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IV & IM Therapy Intake Form

First name*

Last name*

Legal Sex

Male

Female

Birthday*

Month

Day

Year

Phone Number

Communication Preferences: Do you prefer texts or telephone calls?

Texts

Phone call

Either text or phone call

Multi-line address

Country/Region

Address

City

Zip / Postal code

Is this address a hotel or office?

Yes

List any allergies below and what type of reaction. If none, please indicate this. Please also indicate if you allergic to metals or foods such as corn*

Describe the symptoms you are having. (Ex: Headaches, hangover, wellness, dehydration, vomiting)*

Please list current medications you take regularly. Please write 'none' if not taking any medications.*

Medical History

Heart failure/CHF

Recent abnormal labs of any kind (please specify which labs and their levels in medical history above)

High ferritin

Low ferritin

Cancer

Kidney disease/failure/kidney problems

Liver disease/liver failure/ liver problems

Pregnant

Lactating

Patient is under 18

High blood pressure

Pulmonary Edema

COPD

Emphysema

Anasarca

Ascites

Current chest pain

Shortness of breath

Diabetes (please indicate type 1 or type 2 in medical history section above)

I agree to a complete a telehealth visit to confirm my medical history is true and correct. *

I understand there is a one time $35 new patient fee that will be added to my first treatment.

Signature

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