The IV Hub Patient Enrollment Form

Name

First Name Last Name

Date

Month Day Year

Date of Birth

Month Day Year

Phone Number:

E-mail

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

In case of emergency

Emergency Contact:

First Name Last Name

Relationship

Contact Number

Weight (pounds)

Height (inches)

Taking any medications, including herbal supplements currently?

Yes No

Are you on a blood thinner?

Yes No

Do you have any Allergies to medications?

Yes No

If yes, please list it here with reaction

What is your past medical history?

Have you been diagnosed with congestive heart failure or coronary artery disease?

Have you been diagnosed with liver disease?

Have you been diagnosed with diabetes?

Have you been diagnosed with kidney disease

Any history of GI bleeding?

Are you pregnant or breastfeeding?

If not pregnant, date of last menstrual period

Please be advised that if you answered yes to any of the 6 questions, you may be denied services for safety reasons

What Treatment Are you Interested in Today?

1. Immunity: 1 liter of normal saline, Vitamin C 500 mg, Vitamin Complex and Zinc 2. Inner Beauty: 1 Liter of normal saline, Vitamin Complex, and Biotin 3. Hangover: 1 liter of normal saline, Vitamin and Mineral complex, and Zofran (nausea) 4. Recovery and Performance: 1 Liter of normal saline, Vitamin C, vitamin and mineral complex, and amino acid blend 5. Vitamin B12 Intramuscular Injection 1000 mcg (NOT ALLOWED if allergic to Sulfa or Cobalt) *IMPORTANT: Vitamin C infusions are NOT ALLOWED 7 Days before Surgery 6. Migraine Relief: 1 Liter of normal saline, Zofran for nausea and Toradol for pain

I attest that I am not experiencing any of the following:

1. Fever greater than 100 degrees, chills or sweating

2. New or worsening cough, sore throat

3.Shortness of breath, body and/or muscle aches not associated with exercise

4.Headache with other COVID symptoms

5.New loss of taste or smell

6.Nausea, vomiting or diarrhea

7.Unusual fatigue with other Covid symptoms

8.Close contact with anyone confirmed with Covid

9. Have not traveled outside MA in last 2 weeks

Terms and Conditions Accepted

Clear