Client Intake Form

First Name

Last Name

Address

Street Address

Street Line 2

City

State

Postal Code

Weight

Height

Gender

Email

Date of Birth

Phone Number

Drivers License #:

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

Which Treatment are you interested in?

Have you ever had an infusion before?

Yes No

Have you ever done Hormone replacement therapy before?

Yes No

Have you got blood work done in the past 30 days?

Yes No

General Health

Excellent Good Fair Poor

Medical History - Identify any present and past health concerns.

Hypertension

Past Present

Abnormal Heart Rhythms

Past Present

Bleeding/Clotting Disorder

Past Present

Sudden Weight Loss

Past Present

Chest Pain

Past Present

Chronic Heart Failure

Past Present

CVA/Stroke/TIA or mini-stroke

Past Present

Thyroid Problems

Past Present

Kidney Disease

Past Present

Depression

Past Present

Anxiety/Panic Attacks

Past Present

Asthma

Past Present

Diabetes

Past Present

Ankle Swelling

Past Present

Generalized Edema

Past Present

Are you pregnant?

Past Present

Allergic Reactions

Past Present

Seizures

Past Present

Anemia

Past Present

Head Injury

Past Present

Comments on your Medical History

Details of any of the above or any other medical considerations, i.e.: Autoimmunity, chronic illnesses, mold toxicity, viral illness, parasites, bacteria/yeast infection, neurological conditions, alcoholism, cancer, frequent infections, arthritis, nutritional deficiencies, etc.

Describe any current symptoms and duration if not addressed above, i.e.: GI upset, skin problems, pain, inflammation, headaches, sleep problems, fatigue,

Treatments or therapies tried:

Have you had a COVID-19 vaccination and Booster? If yes, please indicate when you received your last dose. If you plan on getting the vaccine soon, please indicate your scheduled date as this is important when considering IV therapy. Also note if you have received a Booster and date.

Current Medications: (Include prescriptions, over-the-counter medicines, supplements/vitamins, etc. with dose/frequency)*

Allergies to any medications or foods: (List medication or food and reaction)*

Do you follow a special diet? if so, please describe.

Do you exercise? if so, what type of exercise?

How did you hear about us?

Signature

Type your Legal Full Name to Sign

Date of Sign

Consent

I have read the Consent Terms & Conditions and Agree.

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

Client Intake Form

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