Medical History
Full Name (Nombre)
*
First Name
Last Name
Email/Correo electronico
example@example.com
Address (Domicilio)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Telefono)
*
Format: (000) 000-0000.
Birth Date (Fecha de Nacimiento)
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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13
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2004
2003
2002
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age (Edad)
*
What is your Gender?/Sexo
*
Male/Masculino
Female/Femenino
Weight in pounds (lbs) (Peso en libras)
*
Do you have any of the following? if you have ANY of the following you are not a candidate for our IV services. (Tiene algunas de las siguientes enfermedades? Si tiene alguna de ellas no es candidato para recibir nuestro servicio de suero intravenoso)
*
Congestive Heart Failure (Insuficiencia Cardiaca)
Chronic Kidney Disease (Insuficiencia Renal Cronica)
Kidney Failure or on Dialysis (Insuficiencia Renal o paciente de dialisis)
Clotting disorder or use blood thinners (Desorden de coagulacion o uso de anticoagulantes)
Liver disease (Insuficiencia de higado)
None (Ninguno)
List any current medical problems or chronic illnesses? (Problemas de salud o enfermedades cronicas)
*
Are you currently pregnant? (Esta embarazada actualmente?)
Please Select
Yes
No
If pregnant, how many weeks? (Semanas de embarazo)
What are we treating you for today? (Que sintomas tiene?)
*
Nausea/Vomiting (Nausea/vomito)
Dehydration (Deshidratacion)
Hangover (Resaca)
Cold/Flu (Gripe/Influenza)
Covid-19 symptoms (Sintomas de Covid)
Headache/migraine (Dolor de cabeza o migraña)
Wellness (Salud)
Other
if other please enter here (cual otro sintoma?)
Which treatment would you like? (Que tratamiento necesita?)
*
Please Select
Immunity
Hangover
Myers
Custom bag
B12 Injection
Toradol Injection
MIC Injection
Zofran Injection
Are you currently taking any medication (including over the counter)? (Esta tomando medicamentos incluyendo medicamentos sin receta?)
*
Yes
No
Enter medication(s) name, dose, frequency (Nombre de medicamento, dosis, frecuencia)
Do you have any medication/food/latex allergies? (Alergias a medicamento, comida, o al latex?)
*
Yes
No
Not Sure
Medication you had a reaction to and type of reaction (Medicamento al cual tuvo alergia y cual fue la reaccion?)
Any known Covid-19 exposure? (Fue expuesto a COVID?)
*
Please Select
Yes
No
Please upload picture of your I.D. (Foto de su identificacion)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photo/Video Release: I, hereby grant and authorize Revive Infusion AZ the right to take, edit, distribute and make use of any and all pictures or video taken of me to be used in and/or for any lawful promotional material including but not limited to advertisements, posters, social media, websites, and other print and digital communications. I waive the right to inspect or approve any finished product in which my likeness appears. I understand and agree that these materials shall become property of Revive Infusion AZ. I hereby hold harmless and release Revive Infusion AZ from all liability. (Autorizacion de fotos/video para el uso completo de Revive Infusion AZ)
*
Yes, I consent
No, I do not consent
HIPAA DOCUMENT
By signing below I consent to treatment and attest I have answered all questions regarding medical history, medications, and personal information truthfully and to the best of my knowledge. I acknowledge it is my responsibility to inform Revive Infusion AZ of any healthcare problems or issues I am currently experiencing. Side effects of treatment (infection, blood clots, air embolism, bruising and redness and injection site, pain, fast or slow heart beat, headache, shortness of breath, swelling, dizziness) have been explained and understood. I understand the services provided have not been evaluated by the Food and Drug Administration (FDA) and these products are not intended to diagnose, treat, cure, or prevent any disease. I consent to treatment and do not hold Revive Infusion AZ or any of their employees liable for any injury or complication I experience during or after treatment.
Date
*
-
Month
-
Day
Year
Date
RN Note:
Vitals and summary.
Submit
Should be Empty: