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IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
Home
About Us
Services Offered
IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
Book Now
Medical Screening Checklist
Medical Screening Checklist
Patient Name
Date of Birth
Date
Email Address
Location (Mobile)
Chief Complaint / Reason for Visit
Dehydration
Fatigue
Immune Support
Recovery
Headache
Nausea
Other
Other Complaint
Medical History:
Hypertension
Heart Disease
CHF
Kidney Disease
Liver Disease
Diabetes
Asthma
Seizures
Cancer
Blood Disorders
Anxiety with IVs
None
Current Symptoms Today
Chest Pain
Shortness of Breath
Fever
Dizziness
Nausea
Headache
None
Allergies
Current Medications / Supplements:
Pregnancy Status
Not Pregnant
Pregnant
Unsure
N/A
Vital Signs
BP:
HR:
SpO
2
Temp
IV Eligibility:
Cleared
MD Approval Required
Not Appropriate Today
Patient Signature
Date
RN Signature
Date
Medical Director Signature
Date
Submit
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