New IV Therapy Request Form First Name Last Name Phone Email Your Location What Are We Treating Today? May You Please Allow Us To Ask Some Preliminary Screening Questions? Yes No Will you provide us some brief answers on your past medical history. The answers to these questions are pertinent to understanding the best therapies available to our clients and eligibility. ***Once your appointment is confirmed you will have to fill out an additional intake form!*** Mahalo for understanding CHF (Congestive Heart Failure) Yes, Known History Of No Known History Renal Failure, CKD (Chronic Kidney Disease) and/or Advanced Kidney Disease Yes, Known History Of No Known History Blood Clotting Disorder Yes, Known History Of No Known History Cirrhosis, Advanced Liver Disease Yes, Known History Of No Known History Are You Pregnant or Nursing Pregnant Nursing N/A Do You Have Any Known Allergies Yes (Please Fill Out Line Below) No Please List Any Allergies Please List Below Any Medications Or Supplements You Are Currently Taking. Any Additional Information? Do you have any other medical history, concerns or information we should know about before scheduling your IV therapy? Please Feel Free To Call Or Text (808) 333-9499 Submit You Will Be Redirected To Our Booking Page Upon Completion Of Our Onboarding Form
