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IV Hydration Therapy Intake Form

Please fill out the following form as complete as possible:

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Name:
Gender:
WHAT ARE YOUR MAIN COMPLAINTS? (Select all that apply)
Which statements best describe why you are here today? (Please check all that apply)
Have you ever been told you have an electrolyte imbalance or other abnormal labs? (Please check all that apply)
Do you have any of the following conditions? (Please check all that apply)
Are You Currenty Breastfeeding:
Are You Diabetic?
Are You A Smoker?
Do You Use Recreational Drugs?
Do you take Digoxin (Lanoxin) for a heart problems?
Do you take any diuretics or water pills?
Do you take any steroids, i.e. prednisone?
Do you have any medication or food allergies?

VITALITY WELLNESS

 

HIPPA Authorization for Release of Patient Health Information

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In general, HIPPA (Health Insurance Portability & Accountability Act) gives patients the right to request the uses and disclosures of their protected health information (PHI). The patient is also provided the right to request confidential communications, or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of home. This information will remain in effect until revoked in writing, except to the extent that action has already been taken.

I Want To Be Contacted By Phone:
I Want To Be Contacted By Work Telephone Number:
I consent and authorize the release of NORMAL test results to the following:
I consent and authorize the release of ABNORMAL test results to the following:
I consent and authorize your office or a facility on on my behalf, to conduct benefit verification services:
I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s).
Do You Have An Advanced Directive (Living Will)?

Thanks for submitting!

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ALL RIGHTS RESERVED ©2024 BY VITALITY WELLNESS- TX FORT WORTH MED SPA

   1201 Summit Ave #400 Fort Worth, TX 76102

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The services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. The material on this website is provided for informational purposes only and is not medical advice. Always consult your physician before beginning any treatment or therapy program. Any designations or references to therapies are for marketing purposes only and do not represent actual products.

PRIVACY POLICY
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