Call Us Now

734-788-6918
LOCATION : 6425 N Canton Center Rd Studio #19, Canton, MI 48187

Email Us

patelnibha60@gmail.com

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IV Drips/ Booster Shots
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Health Screening
- Injection Consent Form
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Home
About
IV Drips/ Booster Shots
Book Appointment
Testimonials
Health Screening
- Injection Consent Form
Contact Us
FAQ
Packages

Health Screening

Name: Replenish Wellness Infusion IV Hydration/Therapy & Vitamin Shots
Price range: $

Pre-Appointment Health Screening Form

Fill out this form before your arrival to expedite your appointment.

For your protection and safety, this form is securely sent to our providers for review.

Todays Date*

Name*

Last

Date of birth*

Gender*

Address*

Phone*

Email*

Emergency Contact Name*

Last

Emergency Contact Phone Number*

Relationship to emergency contact*

Drug Alergies?*

Latex allergy?*

Yes No

Are you currently taking any prescription medications or supplements?

Have you recently been diagnosed with COVID-19 or are you experiencing any symptoms of COVID-19? (Fever, chills, loss of taste/small, cough,nausea, diarrhea?)*

Please check all applicable medical conditions*

High blood pressure Heart failure (CHF) Kidney disease Diabetes Arrythmia Blood clotting or bleeding disorder Liver disease History of syncope (fainting) Ankle swelling/Edema Myocardial infarction (heart attack) Pregnant or breast feeding Anxiety or panic attacks None

Reason for IV Hydration Therapy?*

Have you ever had IV Hydration/Vitamin therapy before?*

Yes No

If yes, how was your experience? Did you have any complications or side effects?*

Do you have any questions or concerns regarding IV Hydration therapy prior to your services?*

Do you have a history, or current use, of injectable/intravenous drug use?*

Yes No

Get In Touch

	CALL US NOW 734-788-6918
	LOCATION 6425 N Canton Center Rd Studio #19, Canton, MI 48187

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Contact Us

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	CALL US NOW 734-788-6918
	LOCATION 6425 N Canton Center Rd Studio #19, Canton, MI 48187

Quick Links

Home
About
Service Menu
Packages
Contact Us

Home
About
Service Menu
Packages
Contact Us

Information

Book Appointment
Testimonials

Book Appointment
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