Medical Intake Form
Please fill out this form to help us understand your health background and current concerns.
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Purpose of Treatment
IV hydration therapy involves the intravenous administration of fluids, electrolytes, vitamins, and/or medications to rapidly restore hydration, replenish essential nutrients, support immune function, boost energy, relieve symptoms, and promote overall wellness. By delivering 100% absorption directly into the bloodstream—far more effective than oral supplements—this treatment provides fast relief from dehydration, fatigue, hangover symptoms, jet lag, migraines, muscle soreness, or chronic conditions, while also enhancing athletic recovery, strengthening immunity, improving skin clarity, and supporting cellular repair and anti-aging through premium infusions like Myers Cocktail, NAD+ Cellular Recharge, and Glutathione. Your customized blend is carefully selected based on your health goals and medical screening to help you Recharge, Recover, and Rehydrate safely and efficiently.
Possible Risks and Side Effects
IV hydration therapy is generally safe when administered by a licensed registered nurse. However, as with any medical procedure, possible side effects may include:Pain, redness, swelling, or bruising at the IV insertion siteVein irritation or phlebitis (inflammation of the vein)Infection (rare, prevented with sterile technique)Allergic reaction to fluids, vitamins, or additivesDizziness, lightheadedness, or fainting (especially if standing quickly)Nausea, headache, or flushing during infusionElectrolyte imbalance or fluid overload (extremely rare with proper screening)Air embolism or blood clot (very rare with standard protocols)Our team follows strict medical guidelines to minimize risks. You will be monitored throughout your session, and treatment can be stopped at any time.
Acknowledgment and Consent
I acknowledge that I have provided a complete and accurate medical history, including all known conditions, medications, allergies, and prior reactions to IV therapy. I understand the purpose, benefits, and potential risks of IV hydration therapy as explained above. I voluntarily consent to receive IV therapy from IV League Hydration. I release IV League Hydration, its nurses, staff, and affiliates from any liability related to treatment outcomes, except in cases of gross negligence or misconduct. I understand I may refuse or stop treatment at any time without penalty.
Client Signature
Date
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Vitals
Provider Notes
Initials
IV Treatment Information
Date of Birth
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Month
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Day
Year
Date
Date of Service
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Month
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Day
Year
Date
Provider
IV Treatment Details
Brown (Basic Hydration)
Harvard (Myers Cocktail)
Columbia (Migraine & Tension Relief)
Penn (Immunity Boost)
Princeton (Energy & Focus)
Yale (Detox & Glow)
Dartmouth (Hangover Recovery)
Cornell (Performance & Recovery)
NAD Cellular Recharge
Other
If Other Specify
Fluids Used
Additives / Vitamins
Total Volume (mL)
Infusion Site
Left Arm
Right Arm
Other
Pre Treatment Vitals
Blood Pressure
Heart Rate
O2
Temp
Post Treatment Vitals
Blood Pressure
Heart Rate
O2
Temp
Client Response / Notes
Tolerated Well
Yes
No
Comments
Provider Section
Provider Name
Signature
Date
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Month
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Day
Year
Date
Follow-Up / Recommendations
Increase Fluids
Rest
Return for Maintenance Drip
Other
Submit
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