Client Intake Form

Client Intake Form
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Emergency Contact Info
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Emergency Contact
About You
What are your main complaints?(Please check all that apply)

Fatigue/ Low EnergyStressPoor DietLow Mood/ DepressionWeight GainRecent SurgeryCold/Flu/COVID symptomsBrain Fog/ Trouble ConcentratingDifficulty Losing WeightDull or Dry SkinHeadache/MigraineRecent Illness/ InjuryPerformance Enhancement
Please briefly describe why you are seeking IV infusion or injection therapy? For example: Are you looking to improve your energy, skin/hair/nail quality, recovery times, immune system, or hydration status? Are you seeking treatment for a hangover or looking to feel and look better?
Medical History
Allergies(Medications, foods, etc.):
Current Medications: (Please include OTC & supplements)
CARDIOVASCULAR AND RESPIRATORY

High Blood PressureHeart MurmurValve DisorderAbnormal RhythmChest PainHeart AttackCardiac Surgery or StentsCongestive Heart FailurePeripheral Artery DiseaseThrombosis or DVTAneurysmAsthmaCOPDSleep ApneaShortness of BreathPulmonary HypertensionLung CancerOther
GASTROINTESTINAL AND URINARY

Acid RefluxLiver DiseaseBladder DiseaseHepatitis A, B, CKidney DiseaseOther
METABOLIC/ENDOCRINE/AUTOIMMUNE

Hyper/Hypo ThyroidRheumatoid ArthritisDiabetes Type I Type IIHx of DKALupusOther
NEUROLOGIC

Stroke/TIAMultiple SclerosisParkinson’sAlzheimer’sSeizuresOther
HEMATOLOGY

Anemia(Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)MTHFRG6PD DeficiencyOther
MUSCULOSKELETAL

Back PainDegenerative Joint DiseaseCarpal Tunnel SyndromeDegenerative Disk DiseaseFibromyalgiaOther
PSYCHOLOGICAL

DepressionAnxiety or Panic AttacksSuicidal IdeationsBi PolarOther
CANCER

ChemotherapyRadiationCancerOther
Any chance that you are pregnant?

YesNoOther
Are you currently breastfeeding?

YesNo
Pain

CRPSFibromyalgia
Do you drink alcohol or use any types of drugs? If so, please explain
Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?
Would you like to tell us anything else that you feel like is important?
I attest that the information I have provided is true and accurate to the best of my knowledge:
Indemnification Clause

I, ______________________________, agree to indemnify, defend, protect, and hold harmless the medical providers employed by Essential IV and Wellness; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Essential IV and Wellness; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Essential IV and Wellness; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Essential IV and Wellness;. I am aware of the potential side effects associated with IV infusion and injectable therapies provided by Essential IV and Wellness accept all the risks involved with IV infusion and injectable therapies and will not seek indemnification or damages from the indemnified parties.
Signature

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Disclosures
Signature

Clear
I consent and authorize Essential IV & Wellness, LLC to use my likeness in any photograph, video or other digital media (“Photos”) taken or to be taken in any and all of its publications, including print and or web-based publications.
B. I irrevocably authorize Essential IV & Wellness, LLC to copy, edit, enhance, crop, or otherwise alter any photo for use in their publications. I also waive any rights for approval of inspection of any photos.
C. I acknowledge that I am not entitled to any compensation or royalties with respect to the use of the photos.
D. I agree to release and forever discharge Essential IV & Wellness, LLC and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them, in their agreements, disputes, demands, damages, causes of action of any nature of kind, known or unknown, which I, and anyone claiming on behalf of me, may have or claim to have against Releasee in connection with this release.
E. I have carefully read and fully understand all the provisions of this Photo Release Form and am freely, knowingly and voluntarily signing.
Signature

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Should be Empty:

Client Intake Form

Emergency Contact Info

About You

Medical History

Disclosures