Medical Intake form

Date*

Date

Method of payment*

Amount paid*

Name*

First NameLast Name

Email

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Emergency Contact and Contact Number*

Have you had any changes since your last visit?*

YesNo

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

Do you have any allergies?

YesNo

If yes, please list.

Medical History

	Yes	No
Heart Attack
Other Heart disease
Stroke
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Kidney Disease
Liver Disease
Thyroid Disorder
Bleeding Disorder
Asthma
Seizure Disorder
Cancer
Anemia
Pregnant or Breastfeeding
Immune Deficiency
Recent Surgery (last 30 days)

Other medical history you would like us to know about

Current Medications

IV infusion administered*

Add-ons

Other add-ins

SIGNATURE PAGE

Patient Consent

- I understand that IV infusion therapy involves the administration of vitamins, minerals, amino acids or fluids directly in the blood stream.

- I understand that, as with any medical procedure, there are risks including but not limited to bruising, infection, vein irritation, allergic reaction, or infiltration.

- I have informed the provider of all known medical conditions, medications and allergies.

- I understand results may vary and are not guaranteed

- I consent to recieve the IV infusion treatment today.

- I release Beauty Shots, LLC, and its providers from any liability related to this treatment, except in cases of negligence

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.

Post infusion considerations

- You may experience mild bruising or tenderness at the IV site.

- Drink plenty of fluids for the next 24 hourss.

- If you experience redness, swelling, pain, dizziness, or shortness of breath, contact us at (325)668-3480 or seek medical care immediately.

- Resume normal diet and activity unless otherwise instructed.

Please select one of the following

I authorize Beauty Shots LLC to discuss my goals, treatment, and services in an open setting where others may be present.I do NOT authorize discussions of my health or treatment in a shared area and prefer to have all conversations in a private space.

Client Signature*

PROVIDER ONLY DOCUMENTATION BELOW

IV site*

Gauge*

202224

IV performed by*

Provider Signature*

Date*

Date