Client Intake Form - TK H2O IV Hydration & Wellness

Full Name *

Today's Date *

Address

Apt, suite, etc.

Country

City

State

Zip code

Email *

Username *

Password *

Phone *

Date of Birth *

Age *

Emergency Contact *

In case of emergency, name and phone number of person you want us to contact.

Medications?

List all medications you are currently taking.

Allergies *

List all known allergies. Enter 'N/A' if you are unaware.

Have you ever had IV Hydration before?

Any problems that occur when you are injected?

Current Health Issues?

Select *

I consent to all nutrient injections rendered by the the licensed professional medical staff associated with TK “H2O” IV Hydration and Wellness. I understand that there are risk to vitamin nutrient injections including but not limited to pain, bruising, inflammation, injury, infection, allergic reactions, headaches, dry mouth, difficulty sleeping, diarrhea, blurred vision, unpleasant taste, increase urination, cramps, and metabolic disturbances. I do not expect the persons employed or associated with TK H2O IV hydration and wellness to anticipate and or explain all risk and possible complications. I hereby release the professional medical staff at TK “H2O” IV Hydration and Wellness from all liabilities regarding my treatment with vitamin/nutrient injections. I understand that nutrient injections may not be approved by the United States Food and Drug Administration for the treatment of my medical condition.

E-Signature *