Thrive at Home Primary Care Check-In

Thrive at Home Primary Care

IM Injection Services
Please complete this quick check-in prior to receiving your injection today. This allows the Nurse Practitioner to review your health information and ensure safe, appropriate care. This form takes approximately 2–3 minutes to complete. All services are self-pay and provided by a licensed Nurse Practitioner.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Section 2: Health Screening
Medical History*

High blood pressureHeart diseaseKidney diseaseDiabetesStrokeCOPD or asthmaCancerThyroid diseaseDementia or memory problemsDepression or anxietyBreast feeding or pregnantOther
Allergies*
Please list any medication, food, latex, or environmental allergies and the reaction if known.
Current medications, including over-the-counter products and supplements*
Current symptoms or reason for visit*
⚠️ Please pause and speak with the Nurse Practitioner before proceeding. Based on your responses, additional review is needed to ensure your safety prior to receiving an injection today.
I understand I need to speak with the Nurse Practitioner before receiving treatment*
Select Your Injection Service
Select Your Service

Energy BoostMetabolism SupportAllergy & Sinus ReliefRecovery BoostPain & Inflammation ReliefCellular Glow BoostRestore & ReplenishIm not sure Id like help choosing
Service Details

Energy Boost: B12

Metabolism Support: Metabolism Support Blend + B12

Allergy & Sinus Relief: Diphenhydramine + Dexamethasone

Recovery Boost: B12 + Dexamethasone

Pain & Inflammation Relief: Toradol + Dexamethasone

Cellular Glow Boost: Glutathione

Restore & Replenish: Vitamin C + B12
Consent for IM Injection Services
I consent to receive intramuscular injection services provided by Thrive at Home Primary Care PLLC. I understand that these services are elective wellness treatments and are not a substitute for primary or emergency medical care. I acknowledge that I have disclosed my full medical history, medications, and allergies to the best of my knowledge. I understand the potential risks, including pain at injection site, bruising, bleeding, infection, allergic reaction, dizziness, or other unforeseen complications. I understand that results are not guaranteed. I understand that a Nurse Practitioner will assess my appropriateness for treatment and may decline services if clinically indicated. I consent to treatment and understand I may withdraw consent at any time.
Patient Signature*
Financial Agreement
All services provided today are self-pay. Payment is due at the time of service. No insurance billing will be submitted. All sales are final and non-refundable once services are administered.
Financial Agreement Signature*
Privacy Acknowledgment
I acknowledge that I have been informed of my rights regarding the privacy of my health information. I consent to Thrive at Home Primary Care PLLC using and disclosing my health information for treatment, payment, and healthcare operations.
HIPAA Acknowledgment Signature*
Date*

MonthDayYear
Date
Section 7: Marketing Consent
Do you consent to photos or videos being used for marketing purposes?

YesNo
Section 8: Marketing Question
How did you hear about Thrive at Home?

InstagramFacebookFriendEventOtherOther
Provider Use Only

Please leave this section blank. This portion is completed by the medical provider only.
NP Notes / Clearance
Provider Assessment
Medication

Glutathione — Lot C09A01-26 — Exp 08/2026Lipo MIC — Lot C07A02-26 — Exp 07/2026Dexamethasone — Lot J25047 — Exp 09/01/2027Diphenhydramine — Lot M25063 — Exp 12/01/2027Ascorbic Acid — Lot B11A01-26 — Exp 08/10/2026Ondansetron — Lot L31A03 — Exp 06/26/2029Cyanocobalamin — Lot L17A03 — Exp 06/14/2026Ketorolac — Lot G2010301 — Exp 10/01/2027
Injection Site

Left gluteRight gluteLeft deltoidRight deltoid
Injection Details
Amount / Number (default 1 mL)
Route

IMIV
Blood Pressure
Heart Rate
Patient Response

Tolerated wellMild sorenessMild rednessMild dizzinessNauseaOther
Complications

NoneBleedingBruisingPain at siteSwellingRednessDizzinessNauseaOther
Notes
Should be Empty:

Thrive at Home Primary Care

Section 2: Health Screening

Select Your Injection Service

Consent for IM Injection Services

Financial Agreement

Privacy Acknowledgment

Section 7: Marketing Consent

Section 8: Marketing Question

Provider Use Only

Provider Assessment