IV Therapy Intake Form

IV Therapy Intake Form

By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement in your behalf.

Name(Required)
Date Of Birth(Required)

General Health Information

Statement of No Health Problems
Statement Of No Allergies/Sensitivities
Do you exercise?(Required)
Do you take vitamins?(Required)
Do you drink water(Required)

MEDICAL HISTORY

Illnesses/Conditions
Check appropriate Box: Currently- Condition you currently have PAST - Condition you’ve had in the past Leave Unchecked If Not Applicable

MEDICATIONS AND SUPPLEMENTS

Medication/OTC/Supplements Include: Dosage, Frequency, Last Taken
Have you ever had IV or injectable vitamin therapy?(Required)

DIAGNOSTIC STUDIES

Please indicate if you have had any of the following diagnostic studies, providing dates and test results as applicable
Do you currently follow any of the following special diet or nutritional program?
Check all that apply

ACKNOWLEDGEMENTS AND CONSENT

To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.
By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement in your behalf.