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IV Hydration Therapy Intake Form

Please fill out the following form as complete as possible:

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WHAT ARE YOUR MAIN COMPLAINTS? (Select all that apply)
Which statements best describe why you are here today? (Please check all that apply)
Have you ever been told you have an electrolyte imbalance or other abnormal labs? (Please check all that apply)
Do you have any of the following conditions? (Please check all that apply)
Are You Currenty Breastfeeding:
Are You Diabetic?
Are You A Smoker?
Do You Use Recreational Drugs?
Do you take Digoxin (Lanoxin) for a heart problems?
Do you take any diuretics or water pills?
Do you take any steroids, i.e. prednisone?
Do you have any medication or food allergies?



HIPPA Authorization for Release of Patient Health Information

In general, HIPPA (Health Insurance Portability & Accountability Act) gives patients the right to request the uses and disclosures of their protected health information (PHI). The patient is also provided the right to request confidential communications, or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of home. This information will remain in effect until revoked in writing, except to the extent that action has already been taken.

I Want To Be Contacted By Phone:
I Want To Be Contacted By Work Telephone Number:
I consent and authorize the release of NORMAL test results to the following:
I consent and authorize the release of ABNORMAL test results to the following:
I consent and authorize your office or a facility on on my behalf, to conduct benefit verification services:
I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s).
Do You Have An Advanced Directive (Living Will)?

Thanks for submitting!

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