Client Intake Form

Name(Required)
Address(Required)
Date of Birth(Required)
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Max. file size: 50 MB, Max. files: 10.
    As a telemedicine provider company, your picture ID (driver's license, State ID, or passport) is a prerequisite for any of our services to verify your age and identity
    Have you ever had an infusion before?(Required)
    Have you ever done Hormone replacement therapy before?(Required)
    Have you got blood work done in the past 30 days?(Required)
    General Health(Required)

    Medical History - Identify any present and past health concerns.

    Hypertension
    Abnormal Heart Rhythms
    Bleeding/Clotting Disorder
    Sudden Weight Loss
    Chest Pain
    Chronic Heart Failure
    CVA/Stroke/TIA or mini-stroke
    Thyroid Problems
    Kidney Disease
    Depression
    Anxiety/Panic Attacks
    Asthma
    Diabetes
    Ankle Swelling
    Generalized Edema
    Are you pregnant?
    Allergic Reactions
    Seizures
    Anemia
    Head Injury
    i.e.: Autoimmunity, chronic illnesses, mold toxicity, viral illness, parasites, bacteria/yeast infection, neurological conditions, alcoholism, cancer, frequent infections, arthritis, nutritional deficiencies, etc.
    i.e.: GI upset, skin problems, pain, inflammation, headaches, sleep problems, fatigue.
    Consent(Required)
    This field is for validation purposes and should be left unchanged.

    NYC Infusion provides intravenous therapy to people who want to feel their best and perform at optimal levels.

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    • +1 800 930 8606
    • PO Box 271, Oceanside, NY 11572
    • 2808 Long Beach rd Oceanaide NY 11572
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