Consultation Form

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Consultation Form

Today's Date *

YYYY

First Name *

Last Name *

Date of Birth *

YYYY

Address *

Phone Number *

Secondary Phone Number

E-mail Address *

Is this your first IV Hydration treatment? *

Yes

Are you pregnant and/ or breastfeeding?

Pregnant

Breastfeeding

Neither

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Do you have any of the following health conditions?

Cancer

Cardiomyopathy

Circulation Disorder

Hypertension

Hypotension

Metal Implants/ Braces

Pacemaker or Defibrillator

Diabetes

Claustrophobia

Congestive Heart Failure

Heart Disease

Hormonal Imbalance

Epilepsy or Seizures

HIV AIDS

Hepatitis A/B/C

Migraines/ Headaches

Depression/ Anxiety

End Stage Renal Disease

Spinal Cord Injury

Immune Disorder

Lupus

Blood Clot Disorder

Skin Disease

Fibromyalgia

Menopause

Varicose Veins

Other:

I have completed this form to the best of my knowledge and agree to inform the provider of any changes in the above information. I have been informed and understand any contraindications to the requested treatment and agree I do not have any condition(s) that would make the requested treatment unsuitable, I will inform the provider of any discomfort I may feel during the treatment and allow them to adjust accordingly. I agree to waive all liabilities towards my provider and the employer for any injury or damages incurred due to any misrepresentation of my health history.

My digital signature *

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