Injectable Therapy Screening Form
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which of the following medications are you interested in? (Select all that apply)
Lipo-Mino-Mix (Skinny Shot)
Glutathione
NAD+
I’m interested in a consultation with a medical provider to find the best option for me
Screening Questions
Please check Yes or No for each
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have any known allergy to Glutathione or components?
*
Yes
No
Do you have liver, kidney, or heart disease?
*
Yes
No
Do you have a history of cancer?
*
Yes
No
Do you have a history of asthma?
*
Yes
No
Are you currently taking any prescription medications?
*
Yes
No
Are you taking any supplements or herbs?
*
Yes
No
Have there been any major changes in your health since your last visit?
*
Yes
No
List out all current medication
List out allergies
Intake & Processing Fee
A $35 non-refundable processing fee is required to begin your intake. This fee covers a comprehensive review of your information by a Registered Nurse, who will then collaborate with our Medical Director to determine your eligibility for treatment. Once your intake has been submitted, a member of our licensed staff will reach out to collect the $35 processing fee and guide you through the next steps
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: