IV Therapy Registration Form -

Patient Registration

IV Therapy Patient
Registration Form

For patients seeking IV nutrient therapy, injectable therapies, and in-office wellness infusions. Please complete all sections as thoroughly as possible to help Dr. Thomas design a safe, personalized protocol.

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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.

🔒 Your information is sent securely and directly to Dr. Thomas’s clinical team. A team member will contact you within one business day to schedule your consultation and IV therapy sessions.

Patient Information

First name

Last name

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? (check all that apply)

Additional notes on your interest or specific therapy you have in mind

Current Symptoms & Concerns

What are you looking to address? (check all that apply)

Describe your symptoms and how long you have had them

Medical History & Safety Screening

The following conditions can affect which IV therapies are safe for you. Please answer accurately — Dr. Thomas uses this information to design a protocol that avoids risk.

Do you have any of the following conditions? (check all that apply)

Pregnancy status (if applicable)

Have you had difficulty with IV access in the past?

Additional details about any conditions checked above

Recent Labs & Testing

Recent labs help Dr. Thomas customize your IV protocol and confirm safety. If you have not been tested, select “Never tested” — appropriate labs will be ordered at your consultation.

Recent kidney function (creatinine or GFR)

Vitamin D level

Vitamin B12 level

Ferritin / Iron level

G6PD status (important for high-dose Vitamin C)

MTHFR / methylation status

Other recent labs you would like Dr. Thomas to know about

Current Medications

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

Medications that require special screening (check all that apply)

All current medications with dosages

Current supplements you are taking

Allergies & Sensitivities

IV therapy allergies are essential to identify — particularly sulfa/sulfite (glutathione) and reactions to prior IV medications.

Known allergies or sensitivities (check all that apply)

Describe your allergies and reactions in detail

Lifestyle & Wellness

Current weight (lbs)

Height

Avg 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 (check all that apply)

Frequency preference

Timing preference

What is your biggest goal for IV therapy?

Any questions or concerns about IV therapy you’d like addressed?

Consent and Signature

⚠ Please read and confirm each statement below before submitting.

Electronic signature (type your full legal name)

Today’s date

✅

Registration Received!

Thank you for registering with Sure Success Wellness Center. Dr. Thomas’s team will review your IV therapy history and contact you within one business day to schedule your initial consultation.

Important: If you experience a severe allergic reaction, chest pain, or symptoms of a medical emergency before your appointment — call 911 immediately. Do not wait.

For non-emergency questions please call us at (317) 253-7795.

IV Therapy Registration Form

IV Therapy PatientRegistration Form

Registration Received!

IV Therapy Patient
Registration Form