IV Therapy Registration Form -

EMERGENCY NOTICE: This form is for scheduling future IV therapy sessions. If you are currently experiencing a medical emergency – severe allergic reaction, chest pain, difficulty breathing, or symptoms requiring urgent care – do NOT complete this form. Call 911 immediately

Patient Information

Patient Name

First

Last

Date of Birth

Age

Biological Sex

Phone Number

Email Address

Best Way to Reach You

New or Returning Patient?

How Did You Hear About Us?

Referring Physician Name (if applicable)

IV Therapy Interest

Which Therapies Are You Interested In?

Additional Notes on Your Interest

Current Symptoms & Concerns

What Are You Looking to Address?

Describe Your Symptoms and How Long You've Had Them

Medical History & Safety Screening

These conditions can affect which IV therapies are safe for you. Please answer accurately.

Do You Have Any of the Following Conditions?

Pregnancy Status (if applicable)

Have You Had Difficulty With IV Access in the Past?

Additional Details About Any Conditions Checked Above

Current Medications

Certain medications interact with IV nutrients. Please list all medications accurately.

Medications That Require Special Screening

All Current Medications With Dosages

Current Supplements You Are Taking

Allergies & Sensitivities

Particularly sulfa/sulfite for glutathione and reactions to prior IV medications.

Known Allergies or Sensitivities

Describe Your Allergies and Reactions in Detail

Lifestyle & Wellness

Current Weight (lbs)

Height

Had and Checked

Average Sleep Hours Per Night

Diet Pattern

Daily Water Intake

Alcohol Use

Caffeine Use

Exercise Frequency

Stress Level

Tobacco or Nicotine Use

Known Toxin Exposure

Your Goals & Frequency Preferences

Primary Goals for IV Therapy

(provide choice list)

Frequency Preference

Timing Preference

What Is Your Biggest Goal for IV Therapy?

Any Questions or Concerns About IV Therapy?

Consent and Signature

Please read and confirm each statement before submitting.

Accuracy

I confirm the information above is accurate and complete to the best of my knowledge, including all medications, allergies, and medical conditions.

Consultation Required

I understand IV therapy requires an initial consultation with Dr. Thomas, and that additional lab work may be ordered before treatment begins.

Risks

I understand IV therapy carries risks including bruising, vein irritation, allergic reaction, and, in rare cases, more serious complications. Dr. Thomas will review these at my consultation.

Emergency

I understand that if I experience a severe reaction (difficulty breathing, throat closing, severe hives, chest pain) during or after therapy, I will call 911 immediately and notify the office.

Contact Consent

I consent to Dr. Thomas’s team contacting me by phone or email to schedule my consultation and IV therapy sessions.

Electronic Signature (type your full legal name)

Today's Date