Rely on Nurse Rhonda – New Client Intake & Consent

Rely on Nurse Rhonda – New Client Intake & Consent

Complete your health history, screening questions, and consent for mobile IV hydration, including privacy and emergency acknowledgments.
Client Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / Gender
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Client
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Contact Detail
Health History and Screening
Allergies

Other
List any allergies or reactions
Current medications and supplements
History of heart disease or heart condition?
History of kidney disease or kidney problems?
History of liver disease or liver problems?
History of bleeding or clotting disorder?
History of diabetes?
History of high blood pressure?
Currently experiencing infection or fever?
Pregnant or breastfeeding?
Recent hospitalization or surgery?
Prior IV therapy or IV hydration?
If yes, describe prior IV complications or reactions
Current symptoms and reason for requesting IV hydration
Recent oral intake and hydration
Service Preference and Scheduling
Preferred Service Date and Time
Consent, Privacy, and Acknowledgments
Consent to treatment and acknowledge risks
Electronic signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notice of Privacy Practices acknowledgment
Privacy statement
Cancellation and no-show acknowledgment
Optional marketing and photo consent
Should be Empty:

Rely on Nurse Rhonda – New Client Intake & Consent

Client Information

Emergency Contact

Health History and Screening

Service Preference and Scheduling

Consent, Privacy, and Acknowledgments