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Patient Intake Form 

Health Declaration

Please fill out the following form
prior to your appointment.

Medical History - Select all that apply
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Do you have any of the following allergies?

Contraindications for receiving a Nutrient IV
Contraindications for receiving a Nutrient IV are: High blood pressure or uncontrolled blood pressure, Myasthenia Gravis, Kidney failure, End-stage kidney disease, bleeding or clotting disorders (i.e. hemophilia, etc.), individuals taking digoxin, and heart disease (arrhythmias, atrial fibrillations, cardiomyopathy,

Irregular heartbeats

In rare cases, Nutrient IVs can cause irregular heartbeats if administered to a patient who has a cardiac arrhythmia condition, light-headiness, muscle cramps after, the IV administration, or phlebitis (irritation) at the injection site.

Possible Side Effects

I am aware of the possible side effects and contraindications.

Vitamin B12

Vitamin B12 is contraindicated in Leber’s, which is hereditary optic nerve atrophic condition. I am aware of the possible side effects and contraindications.

Injection Site Pain

Some redness, minor discomfort, small bruising, and bleeding at the injection site may occur.


Prior to receiving treatment, I have been candid in revealing any condition that may influence this procedure as outlined. I will also inform ADVANCE MOBILE IV THERAPY, LLC. Of any changes in my medical history, current medications and/or any changes relevant to this procedure or prior to any future treatments. I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirely. Also, by signing you are allowing us to use any photo’s taking during time of service will be used on our web site and social media outlets. I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that is my responsibility to inform ADVANCE MOBILE IV THERAPY, LLC. Of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.

 Privacy Practices In accordance with the HIPAA Federal Regulations

Notice of Privacy Practices In accordance with the HIPAA federal regulations this establishment in all substories *will not disclose any information about your personal health without your permission. All information received while a patient (and/if when you declined to be a patient no longer) will be kept confidential. By signing this form, you consent to the use and disclose of your protected health information by our staff, and our business associated strictly for the purpose of treatment, payment, and health care operations. You may request that we restrict how we use, and disclosure protected health information for the purpose mentioned above. If you would like to request a restriction, please do so in writing; however, we reserve the right to deny your request every grant your request if we grant your request, we are bound by terms of agreement. You may also revoke this consent in writing; however, information may on treatment /services provided using the prior consent may still be used to disclose for purpose of treatment, payment, or healthcare operations. By signing this form, I grant my consent for the practice to use and disclose my protected health information for the purposes of treatment, payment, and health care operations.

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