New Patient Intake Form

Patient Intake Form

Date / Time

First Name

Last Name

D.O.B

Patient Gender

Phone no.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

How did you hear about us?

Google

Facebook

Walking

Family / Friends

Allergic to any medications

Yes

If any allergies, List here

Have you now or had in the past? 2/4

	No	Yes
High / Low Blood Pressure
Diabetes / Low Blood Sugar

Have you now or had in the past? 3/4

	No	Yes
Any Current Liver Condition
Asthma

I have read and agree to the Terms and Conditions

Checkbox Field

I acknowledge that I have read and understand all of the foregoing statements and that my signature below indicates that I agree to abide by all of the above conditions.

Checkbox Field

I have received a copy of the Privacy Practices Form.

Checkbox Field

I consent to the exchange of treatment information between The CLINIC IV DRIP AND BOTOX and my primary care or mental health provider.

Patient Signature

Sign Here

	No	Yes
Congestive Heart Failure
Any Kidney Problem
Electrolyte Retention

	No	Yes
African/Asian descent
Any Health Condition
Female, Are You Pregnant?
Taking medication