New Patient Registration

Patient Information

Date:

Last Name:

First Name:

Gender:
MaleFemaleOther

Previous Last Name:

Date of Birth:

Age:

Height:

Weight:

Street Address:

City:

State:

Zip:

Primary Phone:

Email Address:

Contact Preferences:
PhoneEmail

May we call and leave messages?
YesNo

Primary Language:

Primary Care Provider:

Provider Phone:

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Emergency Contact

Name:

Phone:

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Medical History

Allergies:

Medications & Supplements:

Surgical History:

Females: Are you pregnant or breastfeeding?
YesNo

Electrolyte imbalance / abnormal labs:
HypermagnesemiaHypercalcemiaHypokalemiaHemochromatosisOther

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Recent Symptoms (past week)

NoneFever/chillsRashChest painDifficulty urinating

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Main Concerns

Fatigue or low energyStressPoor diet due to busy lifestyleBrain fog or trouble concentratingLow mood or depressionHeadaches or migrainesWeight gain or difficulty losing weightSlow metabolismAsthma and AllergiesRecent surgical procedureRecent illnessCold or flu symptomsFacial wrinkles or fine linesDull or dry skinMalabsorption issuesOther

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Past Medical History

AcneArthritisAsthmaHigh Blood PressureLow Blood PressureCancerChronic Fatigue SyndromeCoronary artery diseaseCongestive heart failureCrohn's diseaseDepressionDiabetesEczemaEpstein-Barr VirusG6PD DeficiencyHigh CholesterolHigh TriglyceridesHepatitisHIVHivesHyperthyroidInflammatory bowelKidney ProblemsOverweightParathyroid problems-highPsoriasisRefluxRheumatoid arthritisSarcoidosisSeizuresSickle Cell AnemiaStrokeKidney StonesUlcerative colitisLiver diseaseLupus SLEMigrainesUnderweightVitiligoFibromyalgiaMultiple SclerosisOther

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IV/IM Therapy — Informed Consent

I have had the opportunity to ask questions and discuss the procedure to my satisfaction.

I have fully disclosed my medical history, medications, and supplements.

I understand I have the right to be informed of the procedure, alternatives, and risks/benefits, and may consent or refuse treatment at any time.

I understand IV/IM therapy is not FDA evaluated and not intended to diagnose, treat, cure, or prevent disease.

I accept personal responsibility for all charges.

I understand potential risks may include bruising, slight bleeding, infection, allergic reaction, burning sensation, dizziness, BP/BS changes, and rare side effects such as fever, nausea, edema, upset stomach, difficulty breathing, arrhythmia, stroke.

I have read and understand the informed consent and agree to proceed with IV/IM therapy.

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Signature

Patient Signature (type full name):

Date: