IV Hydration and Vitamin Therapy Intake Form
Welcome to Dripping Wellness! Please fill out this intake form to help us understand your health needs and preferences for IV hydration and vitamin therapy.
Personal Information
First and Last Name
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health History
1. Do you have any known allergies?
*
Yes
No
If yes, please specify:
2. Are you currently taking any medications (prescription or over-the-counter)?
*
Yes
No
If yes, please list:
3. Do you have any medical conditions?
*
Yes
No
If yes, please specify:
4. Do you have any cardiac issues?
Yes
No
If yes, please specify:
5. Have you had any surgeries in the past year?
*
Yes
No
If yes, please describe:
6. Have you ever received IV therapy before?
*
Yes
No
If yes, please provide details:
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Treatment Goals
1. What are your primary reasons for seeking IV hydration or vitamin therapy?
*
Please Select
Rehydration
Energy Boost
Immune Support
Recovery from Illness/Surgery
Skin Health
Other
Other:
2. Are there specific vitamins or nutrients you are interested in?
*
Yes
No
If yes, please specify:
3. How did you hear about Dripping Wellness?
Referral
Social Media
Website
Other
Other:
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Membership Interest
Are you interested in our membership option?
Yes
No
If yes, would you like more information?
Yes
No
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Patient's Signature
*
Date
*
/
Month
/
Day
Year
Date
Continue
Continue
Should be Empty: