FluidFix Personal Information
*Note: Fluid Fix, LLC does not participate in or accept payments from Medicare, Medicaid, or other governmental health care programs or commercial insurance plans and is not subject to the requirements of the Health Insurance Portability and Accountability Act of 1996, commonly known as “HIPAA.” Nevertheless, Fluid Fix, LLC will take reasonable and appropriate steps to safeguard the privacy of your personal health information and will comply with state laws pertaining to requests to access or obtain copies of medical records.
Email address *
Name (Last, First) *
Your answer
Phone (please include area code) *
Your answer
Address including zip code (home, work, other — Where you would like to receive the IV) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
*Only patients age 16 and older may receive treatment from FluidFix LLC -- with parental consent, if a minor
Name of Primary Care Provider *
Your answer
Address of Primary Care Provider
Your answer
What symptoms are bothering you currently &/or what treatments are you interested in?
Your answer
How did you hear about us?
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