New Vitamin Injection Patient Intake
Please Enter the Information Below
Customer Type
PatientID
Patient Information
First Name
*
Last Name
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Female
Male
Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Phone Number
*
Format: (000) 000-0000.
Do you want to receive emails from Wellness Express? (Vitamin Injection Specials, Coupons, Transactional)
*
Yes
No
Which type of emails would you like to receive? (select all that apply)
Promotional (sales and coupons)
Transactional (purchase receipts and remaining injections)
Email Type
Email Address
Emergency Contact
Emergency Contact First Name
*
Emergency Contact Last Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Other
How did you hear about us?
Please Select
Internet Search (Google)
Facebook/Instagram
Friend
My place of employment
Other
Referred By
Back
Next
Patient Consent
Are you pregnant or nursing?
*
Yes
No
Are you allergic to Sulfa?
*
Yes
No
Are you currently taking blood thinners?
*
Yes
No
Do you have Chronic Liver or Kidney Disfunction? (not considering kidney stones)
*
Yes
No
Do you take medication for your thyroid?
*
Yes
No
Consent for Service and Notice of Privacy Practices
Signature
*
Preferred Name (First Name)
Archived?
Submit
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