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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- Health Screening
- Injection Consent Form
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Home
About
IV SERVICES
Book Appointment
Testimonials
HEALTH FORMS
- Health Screening
- Injection Consent Form
Contact Us
FAQ
Packages

Health Screening

Name: Replenish Wellness Infusion
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 Seizures Diabetes Arrythmia Cancer Blood clotting or bleeding disorder Liver disease History of syncope (fainting) Ankle swelling/Edema Myocardial infarction (heart attack) Anxiety or panic attacks

Any other medical condition not mentioned above?*

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

Are you Currently Pregnant?*

Yes No

Are you currently Breast Feeding?*

Yes No

To my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential. All efforts are routinely made to ensure privacy is upheld. PLEASE SIGN OR PRINT NAME BELOW IN THE BOX.

Get In Touch

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

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