Client Intake Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Medical History Do you currently or have a history of any of the following medical conditions: Kidney Disorder Shortness of breath Blood clots Seizures Heart condition Hormonal problems High blood pressure Fainting Diabetes Hepatitis HIV/ARC/AIDS Migraines/headaches Crohn's disease Cancer Asthma Ankle swelling Liver disease Recent weight loss Lupus, scleroderma Other Are you allergic to latex or rubber? Yes No Have you ever had an allergic or adverse reaction with any infusions before? Yes No Do you have any other allergies? Yes No Do you have any fears or phobias around needles? Yes No Do you currently have any active skin conditions or infections? Yes No Are you pregnant or trying to conceive? Yes No Please list below any prescription and/or over-the-counter medication you are currently taking. Submission of this form is acknowledgment of the following: I have read and understand this agreement and all information detailed above. I understand the procedure and accept the risks. I do not hold the practitioners responsible for any conditions that were present but not disclosed at the time of this IV infusion. Thank you!
