Hot Tub Prescription LLC - Patient Intake Form

Which item are you getting a prescription for?*

Have you had any pain in your body in the last six months?*

YesNo

If yes, then where?*

Rate this pain on a scale of 1-10.*

Over the past two (2) weeks, how often have you felt worried, anxious, or on edge?*

Over the past two (2) weeks, how often have you had irregular sleep? (Sleeping too much or too little)*

Over the past two (2) weeks, how often have you felt sad or depressed?*

Over the past two (2) weeks, how often have you felt more angry or more irritated than usual?*

Are you currently pregnant, are attempting to become pregnant or are anticipating becoming pregnant in the near future?*

Do you have any cardiovascular diseases and/or heart conditions?*

List any medical conditions, and/or hospitalizations that you have had in the last year and/or any medications that you are currently taking:*

Are you prone to seizures or have you ever experienced seizures?*

Is there anything that you believe or suspect could, in any way, prevent you from using this medical device or could cause you harm?*

Do you have anything else you'd like to share with the clinician?*

Have you discussed any of these health issues with another physician?*

YesNo

Have you discussed any of these health issues with another physician?*

YesNo

If yes, then what is the physician's name, city and state?*

What is your first name?*

What is your last name?*

What is your date of birth?*

Date

What is your best contact number?*

Please enter a valid phone number.

What state are you in?*

Enter your email address to proceed*

example@example.com

Release Form to Allow Clinician to Share Your Medical Information by Mail and Email*

READ, SCROLL AND SIGN ABOVE WITH CURSOR OR FINGER to Consent for release of information: I understand (acknowledge) that this record might include sensitive information. If I am sharing this record with someone else, they will be able to see all of this information. I give Hot Tub Prescription LLC and any clinician the full permission to share my hot tub prescription letter, which is a document that contains my personal and medical information, via physical mail and email to the entity/entities and/or email addresses I indicate in this questionnaire and to Hot Tub Prescription LLC. I understand that this information will be shared with a third-party and will no longer be confidential and that I will not hold Hot Tub Prescription LLC nor the clinician liable for who sees the information and for how it's used after it is sent out by mail and/or email. I also understand and agree that clinicians and/or Hot Tub Prescription LLC may use third party applications such as Tiny Scanner or other scanning applications, to scan my letter, and private email services to email the letter to me and to any and all email addresses I listed when responding to the questionnaire. I also agree that the clinician and/or Hot Tub Prescription LLC may share my personal and sensitive medical information with me via telephone and/or leave a voicemail on my phone with any and all personal medical information. I agree that the clinician may call and/or email me and disclose personal medical information over the phone and/or email in order to ask me any additional questions regarding my condition or to make any questions necessary to issue, mail or deliver my Hot Tub Prescription letter. Notice: Hot Tub Prescription LLC and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. Revocation: I may revoke this authorization at any time, by NOT SUBMITTING THIS FORM and Exiting this website and I also have to write and submit such a request to the address below: Hot Tub Prescription LLC, 2009 1st Ave E Bradenton, FL 34208. The revocation will take effect when Hot Tub Prescription LLC receives it, except to the extent that Hot Tub Prescription LLC or others have already relied on it. My Rights I understand this authorization is voluntary. I am entitled to receive a copy of this Authorization. SIGN ABOVE WITH CURSOR OR FINGER TO ACCEPT

Please Enter The Mailing Address That You Would Like the First Letter to Be Sent To (Normally, this will be your mailing address):*

Attention (Name of Recipient)

Street Address and Suite/Apt

CityState / Province

Postal / Zip Code

Please Enter the Email Address for the FIRST Recipient (Normally, this will be your email address). We will also send an electronic scan of the signed letter to this email address via email: *

example@example.com

Assigning the Prescription to a Specific Store: Is there a specific store you have already chosen or that you prefer to work with? We need to assign your prescription to a specific store to issue the prescription and mail the original copy directly to the store (If you do not currently have a store chosen, please proceed anyway and you can just email us the information of the store at a later time).*

Yes, I have already chosen a store that I am working with. And I have also already chosen the model of the device I will be buying.Yes, I have already chosen a store that I am working with. But I have not decided on the product I will be buyingNo, I have not yet chosen a store to work with yet. But, I have already chosen a specific device, brand or model.No, I have not yet chosen a store, nor have I chosen a specific device, brand or model at this time.

The name of the store that I am working with is store's name* . The city that the store is located in is city*. The name of the sales representative that I am working with at this store is name (optional).

Please Enter The Address of the Store (Where you are buying your medical device from) That You Would Like the SECOND Original Copy of the Prescription Letter to Be Sent To:*

Attention (Name of Recipient)

Street Address and Suite/Apt

CityState / Province

Postal / Zip Code

Please Enter the Email Address for the Store (We will also send an electronic scan of the signed letter to them by email) *

example@example.com

Have you ever had a hot tub / spa in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a hot tub / spa before.

Have you ever had a swim spa in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a swim spa.

Have you ever had a Plunge Tub / Ice Bath in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a swim spa.

Have you ever had a sauna in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a swim spa.

Have you ever had a cryotherapy chamber in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a swim spa.

Have you ever had a walk-in bath tubs in your life? Was it for a medical reason?*

Yes, but not for medical reasons.Yes, for medical reasons.I've never had a swim spa.

Have you ever had such a medical device in your life?*

YesNo

How soon are you intending to buy this medical device? (hot tub/spa, swim spa, sauna, cryotherapy chamber, plunge tub / ice bath, walk-in bathtub, or other medical device)*

What sized medical hot tub / spa are you looking to purchase? (When choosing the right hot tub for you and your medical condition, consider how much space you may need to comfortably use the tub)*