IV Infusion Therapy — Client Pre-Arrival Health Form
Please complete this form before your appointment. Your information is confidential and used only to ensure your safety.
SECTION 1 — PATIENT INFORMATION
Full Legal Name
*
Date of Birth
*
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Month
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Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Today's Date
*
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Month
-
Day
Year
Date
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
SECTION 2 — GENERAL HEALTH HISTORY
Do you currently have or have you been diagnosed with any of the following? (Check all that apply)
*
Heart disease or heart condition
High blood pressure (hypertension)
Kidney disease or reduced kidney function
Liver disease
Diabetes (Type 1 or Type 2)
Thyroid disorder
Autoimmune condition
Cancer (current or history)
Blood clotting disorder or DVT
Anemia
G6PD deficiency (glucose-6-phosphate dehydrogenase)
Hemochromatosis (iron overload)
Anxiety, panic disorder, or vasovagal syncope (fainting)
None of the above
If you checked any of the above, please describe:
Are you currently pregnant or breastfeeding?
*
Yes
No
Have you had IV therapy before?
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Yes
No
If yes to IV therapy — any prior reactions or side effects?
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SECTION 3 — MEDICATIONS & SUPPLEMENTS
List all current prescription medications (name + dosage):
*
List all vitamins, supplements, or herbal remedies you currently take:
*
Are you on blood thinners (e.g., Warfarin, Eliquis)?
*
Yes
No
Are you on diuretics (water pills)?
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Yes
No
SECTION 4 — ALLERGIES
List any known allergies (medications, foods, substances, latex):
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Do you have any known sensitivity or reaction to any of the following IV ingredients?
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Vitamin C (ascorbic acid) - high dose
Magnesium
B vitamins (B1, B2, B3, B5, B6, B12)
Glutathione
Zinc
Calcium
Saline / IV fluids
None of the above / Unknown
SECTION 5 — CONTRAINDICATIONS SCREENING
These questions help your RN and Medical Director determine whether IV therapy is safe for you today.
Do you have congestive heart failure or a condition that causes fluid retention?
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Yes
No
Have you had a kidney transplant or are you on dialysis?
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Yes
No
Do you have a known sensitivity to high-dose Vitamin C?
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Yes
No
Are you currently receiving chemotherapy or radiation?
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Yes
No
Have you consumed alcohol in the last 24 hours?
*
Yes
No
Is there anything else your RN or Medical Director should know before your session?
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SECTION 6 — DRIP SELECTION
What drip are you scheduled for or interested in?
*
The Clarity Drip - Acne + Congestion (Zinc, High-Dose Vitamin C, B-Complex)
The Radiance Drip - Pigmentation + Glow (Glutathione, High-Dose Vitamin C, Hydration Base)
The Revival Drip - Aging + Repair (Anti-aging, collagen support, cellular repair)
The Balance Drip - Hormonal Skin + Perimenopause (Magnesium, B-Complex, Vitamin C, Zinc, Amino Acids)
Myers Cocktail - Energy + Immunity (Magnesium, Calcium, B-Complex, High-Dose Vitamin C)
Not sure yet - I'd like guidance at my consultation
SECTION 7 - ACKNOWLEDGMENT
By submitting this form, I confirm that
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The information I have provided is complete and accurate to the best of my knowledge.
I understand that withholding or providing inaccurate health information may affect my eligibility for IV therapy services and may increase my risk of adverse outcomes.
I understand this form does not replace the Informed Consent I will sign at the time of service.
I authorize Chi Aesthetics & Wellness, LLC d/b/a Crystal Ngozi Beauty & Esthetics and its Medical Director to use this information to determine the appropriateness of IV infusion therapy for my session.
Client Signature
*
Date
*
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Month
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Day
Year
Date
This form is transmitted securely via JotForm and stored in compliance with HIPAA. Your information will never be sold or shared with third parties.
Chi Aesthetics & Wellness, LLC d/b/a Crystal Ngozi Beauty & Esthetics | IV Infusion Therapy - Client Pre-Arrival Form
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