IV Therapy Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Choice of IV Drip * Myers Cocktail Get Up & Go Alleviate: PMS Quench Brainstorm Reboot Immunity Recovery & Performance Weight Loss Not sure Allergies * Yes No Medications * Please list all medications that you have been prescribed by your doctor: Non prescriptive drugs * Please list any over-the-counter and/or recreation drugs Allergic Reactions * Please list any drugs or other substances that you are allergic to: Hospitalization * Have you been hospitalized in the past month? Yes No Blood Thinners * Do you currently take a blood thinner? Yes No Steroids * Do you currently take or use any type of steroid? Yes No IV Therapy * Have you used IV Therapy in the past? Yes No Veins * Have you had problems drawing blood or issues with IV's in the past due to small veins or other issues? Yes No Pregnant * Are you pregnant Yes No Health Conditions * Please check any health conditions which you have previously or currently experiencing: Allergies Arthritis Cancer Smoking Pregnancy Alcoholism Epilepsy Pacemaker Hysterectomy Kidney Disease Diabetes Transplant Liver Disease Recent Illeness Claustrophobia Heart Conditions Kidney Disorders Muscular Condition Multiple Sclerosis Renal Insufficiency Hormonal Disorders Keloid Scarring Hypoglycaemia Vericose Veins Asthma/COPD Breast Feeding Systemic Diseases Thrombosis or Phlebitis Water Retention Thyroid Disorders Immunosuppression Recent Operation Viral or Bacterial Infection Gastrointestinal Bleeding Anticoagulant Medication Auto Immune Condition Congestive Heart Failure High/Low Blood Pressure Lack of Normal Skin Sensations I Understand: * I have truthfully answered all questions regarding my medical history. I understand that failing to inform the practitioner about my medical issues and/or drug use can lead to serious complications. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my voluntary participation in IV Therapy rests entirely with me. I understand that Destiny Wellness Center and service providers bear no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions. I understand that Destiny Wellness Center/service providers relies upon information provided by me in assessing my suitability to participate in IV Therapy services. I Agree I Disagree Thank you!