Smart PDF Form

VITTA Medicine
IV Hydration Therapy - Medical Screening Form
Patient Information
Full Name:
Date of Birth:

MonthDayYear
Date
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Date:

MonthDayYear
Date
Medical History
Please check if you currently have or have ever been diagnosed with:
Other medical conditions:
Current Symptoms
Are you currently experiencing:
If yes, explain:
Medications
List all medications you are currently taking:
Allergies
Do you have allergies to medications or vitamins?
If yes, please list:
Pregnancy
Are you pregnant or breastfeeding?
Acknowledgment
I confirm that the information provided is accurate and complete to the best of my knowledge.
Patient Signature:
Date:

MonthDayYear
Date
VITTA Medicine
IV Hydration Therapy – Informed Consent
IV hydration therapy involves the intravenous administration of fluids, vitamins, and minerals to support hydration and wellness.
Possible benefits include improved hydration, increased energy, immune support, and relief from fatigue or dehydration.
Potential Risks
Although generally safe, possible risks include:
- Bruising or discomfort at the injection site
- Infection
- Allergic reaction
- Fluid overload
- Vein irritation (phlebitis)
- Dizziness or fainting
Patients with certain medical conditions such as heart disease, kidney disease, or uncontrolled hypertension may not be appropriate candidates.
I understand that IV therapy is considered a wellness treatment and is not intended to diagnose, treat, cure, or prevent disease.
I have had the opportunity to ask questions and consent voluntarily to treatment.
Patient Signature:
Date:

MonthDayYear
Date
Provider Signature:
VITTA Medicine
Medical Aesthetic Treatment – Screening Form
Patient Name:
Date of Birth:

MonthDayYear
Date
Date:

MonthDayYear
Date
Treatment Requested

Other
Medical History
Do you have any of the following:
Other medical conditions:
Medications
List medications:
Allergies
Other:
Pregnancy
Patient Signature:
Date:

MonthDayYear
Date
VITTA Medicine
Medical Aesthetic Procedures - Informed Consent
Aesthetic procedures such as botulinum toxin injections, dermal fillers, microneedling, and PRP treatments are elective cosmetic procedures designed to improve the appearance of the skin.
Potential Risks
Possible side effects include:
- Bruising
- Swelling
- Infection
- Allergic reaction
- Asymmetry
- Temporary discomfort
- Unsatisfactory cosmetic result
Results vary by individual and no guarantees can be made regarding the outcome.
Multiple treatments may be required to achieve desired results.
I acknowledge that I have discussed the treatment with my provider and understand the risks, benefits, and alternatives.
Patient Signature:
Date:

MonthDayYear
Date
Provider Signature:
VITTA Medicine
Bioidentical Hormone Replacement Therapy – ScreeningForm
Patient Name:
Date of Birth:

MonthDayYear
Date
Date:

MonthDayYear
Date
Symptoms
Medical History
Have you ever been diagnosed with:
Other conditions:
Current Medications
Hormone History
Have you previously used hormone therapy?
If yes, type and duration:
Patient Signature:
Date:

MonthDayYear
Date
VITTA Medicine
Bioidentical Hormone Replacement Therapy – Informed Consent
Bioidentical hormone replacement therapy (BHRT) is used to treat symptoms related to hormonal imbalance or decline.
Treatment may involve estrogen, progesterone, testosterone, or other hormones.
Potential Benefits
- Improved energy
- Improved mood
- Better sleep
- Increased libido
- Reduced menopausal symptoms
Potential Risks
Possible risks may include:
- Blood clots
- Stroke
- Cardiovascular events
- Hormonal side effects
- Acne or hair changes
- Fluid retention
Hormone therapy requires medical evaluation and laboratory testing prior to initiation and periodic monitoring during treatment.
I understand the risks and benefits and voluntarily consent to evaluation and treatment.
Patient Signature:
Date:

MonthDayYear
Date
Provider Signature:
Jennifer — if you'd like, I can also quickly create three additional things that clinics almost always forget but are extremely important:
1. Photo consent for aesthetics (very important for before/after marketing)
2. Financial & cancellation policy
3. HIPAA privacy acknowledgment
Should be Empty:

VITTA Medicine

IV Hydration Therapy - Medical Screening Form

Patient Information

Medical History

Current Symptoms

Medications

Allergies

Pregnancy

Acknowledgment

VITTA Medicine

IV Hydration Therapy – Informed Consent

Potential Risks

VITTA Medicine

Medical Aesthetic Treatment – Screening Form

Medical History

VITTA Medicine

Medical Aesthetic Procedures - Informed Consent

Potential Risks

VITTA Medicine

Bioidentical Hormone Replacement Therapy – ScreeningForm

Medical History

Hormone History

VITTA Medicine

Bioidentical Hormone Replacement Therapy – Informed Consent

Potential Benefits

Potential Risks