New Patient Enrollment Form

DRIP LOUNGE

New Patient Enrollment Form
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
DOB:*

MonthDayYear
Date
Gender*

FemaleMaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Weight (pounds)*
Height (inches)
Emergency Contact:*

First name Last name
Phone Number*

Area CodePhone Number
Relationship
Medical History
Taking any medications, currently?*

YesNo
If yes, please list all prescription drugs and supplements you are currently taking with dosage and condition medication is being taken for:
List any allergies or sensitivities:
(Such as sulfas, tape etc.)
Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries:
(such as Liver Disease, Kidney failure, CHF, High blood pressure)
Please check all that apply:*

High Blood PressureLow Blood PressureBleeding DisorderEdemaLiver Disease/CirrhosisPregnancy/BreastfeedingCongestive Heart FailureKidney Disease/Kidney FailureCancerDiabetesG6PD deficiencyLeg swellingArrythmiaAnginaAnxietyElectrolyte ImbalanceAsthmaOtherNONE
Are you currently seeing a physician for any reason?*

YesNo
If yes, explain reason:
By signing below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
Signature*

Clear
Should be Empty:

DRIP LOUNGE