IV Hydration Intake FormI understand that I am submitting a digital form that will not be shared outside of Luxurious IV Therapy. Patient Information Name * First Name Last Name Patient Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Patient Phone * (###) ### #### Patient Email * Date of Birth * MM DD YYYY Sex/ Pronouns * Emergency Contact Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship to Patient MEDICAL HISTORY Do you have any allergies to any medications? * Yes No If you answered yes, what medications are you allergic to? Are you pregnant? * Yes No Are you allergic to any foods? * Yes No Past and Current Medical History Please check if you have any of the following Congestive Heart Failure Kidney Disease Cirrhosis of the Liver Pneumonia Covid-19 Influenza Diabetes Cancer Previous Surgeries If you clicked yes to any of the conditions, please describe or list them Current Medications What kind of medications are you currently taking? (Please list name, strength and dosage of medication) What kind of vitamins are you currently taking? (Please list name, strength and dosage of vitamin) Consent By signing your name below you are electronically agreeing to the terms above, on the day/time the form is submitted. Your information will remain private and will be reviewed for medical clearance. Electronic Signature First Name Last Name Thank you for submitting the IV Hydration Intake form. One of our medical professionals will get back to you regarding your clearance.
