CoreDrip Client Intake Form
Phone: 1-855-693-7477 Email: coredripivinfusions@gmail.com
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name and Number:
*
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Are you pregnant or breastfeeding? If yes, I understand I will need a note from my OBGYN authorizing IV therapy.
*
Yes
No
N/A
Check the conditions that apply to you:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Liver disease
None
Other
Check the symptoms that you' re currently experiencing:
*
Chest pain
Respiratory
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
None
Other
Are you currently taking any medication, supplements or vitamins ?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Is there anything else you would like the provider to know?
*
What are your goals for wanting IV Therapy? Please list. Ex: skin brightening, weight management, GI, allergies, hydration, etc.
*
Please read the following and acknowledge the following by selecting yes or no:
Make sure you are well hydrated prior to your visit. We suggest drinking 1-2 16oz. bottles of water. Dehydration can make it difficult to insert an IV. I have read and understand the preceding information
*
Yes
No
Make sure you eat something prior to your visit. We suggest a high protein snack, such as nuts, seeds, a protein bar, cheese, yogurt or eggs. Low blood sugar can make you feel weak, light-headed or dizzy. I have read and understand the preceding information
*
Yes
No
Depending on your customized IV cocktail, the infusion can be finished in as little as 20-40 minutes or longer. I have read and understand the preceding information
*
Yes
No
I agree to not having any current signs/symptoms/positive results of Covid 19 and that if I do, I must wait the recommended quarantine period prior to seeking treatment at CoreDrip IV Infusions. I have read and understand the preceding information
*
Yes
No
Signature
*
:
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: