IV Infusion/ Vitamin Injection New Patient Intake
Please complete all sections below to help us provide you with the best care.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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Month
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Day
Year
Date
Employer Information
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Job Title
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How did you hear about Vitality Hormones & IV Bar?
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Social Media
Patient/ Doctor Referral
Google
Drive By
If referred by a patient, please list name here...
Has your doctor ever said your blood pressure was too high or too low?
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Please Select
Yes
No
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?
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Please Select
Yes
No
Have you ever been told that you have diabetes?
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Please Select
Yes
No
Have you ever been diagnosed with Kidney Disease?
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Please Select
Yes
No
Have you ever had an adverse reaction to a medication or vitamin infusion?
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Please Select
Yes
No
Are you allergic to any medication or food?
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Please Select
Yes
No
If yes, please list allergies
Are you taking any prescribed medications or dietary supplementation?
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Please Select
Yes
No
Please provide details of the medications / supplements you are taking and the doses.
Please check any of the following symptoms that apply to you.
*
Fatigue
Headaches
Difficulty Sleeping
Dry Skin or Wrinkles
Mood Swings / Irritability
Decreased Mental Focus or Brain Fog
Decreased Motivation
Decreased Mental Focus
Please click if you're interested in learning more about the following services?
*
Hormone Replacement Therapy
Vitamin Injections
Weight Loss Program
Botox or Filler
N/A
Signature of Patient
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