Medical Intake form

Date

Payment Method

Amount paid

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Have you had any changes since your last visit?

If yes, please list. If No, please proceed to the signature page.

Injections administered

Other injections administered

Do you have any allergies?

If yes, please list

Are you under the care of a primary care physician?

Are you pregnant or breastfeeding?

Medical History

Rows	Yes	No
Diabetes
Hepatitis
Herpes
Autoimmune Illness
Irregular Menses
Heart Problems
Hypertension

Other conditions you want us to know about:

Current Medications

SIGNATURE PAGE

Consent for treatment

I understand that I am receiving an intramuscular or intravenous injection as a part of a wellness treatment. These injections may include a combination of vitamins, amino acids, antioxidants, or supportive nutrients. I have been informed of the potential benefits including improved energy, metabolism, immune support, and beauty enhancement. I understand that the side effects are rare but may include injection site discomfort, allergic reaction, or dizziness. I understand this treatment is elective and I consent to proceed under the supervision of a licensed medical provider.

HIPAA Authorization and Acknowledgement for Open Setting Communication

As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present.

To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:

Acknowledgement of an open setting environment

I understand that:

- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area.

- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.

- I am not required to have any personal health discussions in an open setting.

Client Rights

- I understand that I may change my preference at any time by informing a staff member.

- I understand that my choice will not affect my care or access to services in any way.

Please select the following:

Client Signature

Date

PLEASE DO NOT SUBMIT FORM AND HAND TABLET BACK TO STAFF.

PROVIDER ONLY DOCUMENTATION BELOW

Area of injection

Complications?

Administered by:

Provider Signature