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IV Therapy
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Revived Body - Mobile IV Therapy
Intake Form
All customers must complete this Intake Form before receiving an IV from
Revived Body
Client Intake Form
Please fill out the following form in order to participate in our services
Name
Birthday
Age
Gender
*
Male
Female
Rather not say
Address
Email
Phone
Emergency Contact Name
Emergency Contact Phone
Why are you seeking IV infusion or injection therapy?
*
Required
Improve energy/skin/hair/nail quality
Recovery
Boost immune system
Rehydration
Hangover Cure
Other
Allergies (Medications, food, etc)
Current Medications (include OTC and supplements):
Please check any conditions that apply to you:
CARDIOVASCULAR
*
Required
High Blood Pressure
Chest Pain
Cardiac Surgery or Stents
Confestive Heart Failure
No Cardiovascular condition
Other cardiovascular condition
RESPIRATORY
*
Required
Shortness of Breath
Lung Cancer
No Respiratory condition
Other respiratory condition
GASTROINTESTINAL AND URINARY
*
Required
Acid Reflux
Liver Disease
Kidney Disease
No Gastrointestinal or Urinary condition
Other gastrointestinal or urinary condition
METABOLIC/ENDOCRINE/AUTOIMMUNE
*
Required
Hyper/Hypo Thyroid
Rheumatoid Arthritis
Diabetes Type I Type II
No Metabolic/Endocrine/Autoimmune condition
Other metabolic/endocrine/autoimmune condition
NEUROLOGIC
*
Required
Parkinson's
Alzheimer's
No Neurologic condition
Seizures - date of last seizure
HEMATOLOGY
*
Required
Anemia (Iron Deficiency/Pernicious/Aplastic/Hemolytic/Sickle Cell)
G69D Deficiency
No Hematologic condition
Other hematologic condition
MUSCULOSKELETAL
*
Required
Back Pain
Fibromyalgia
No Musculosketal condition
Other musculosketal condition
PSYCHOLOGICAL
*
Required
Depression
Anxiety or Panic Attacks
No Psychological condition
Other psychological condition
WOMEN (non menopausal)
Are you currently breastfeeding?
*
Yes
No
Any chance of pregnancy?
*
Yes
No
I attest that the information I have provided is true and accurate to the best of my knowledge:
Your Signature
Clear
Print Name
Select a date
Submit
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