IV Hydration Patient Intake Form – Medical History & Health Screening Template for IV Therapy Clinics

Streamline your new-client onboarding process with this professional IV Hydration Patient Intake Form & Medical History Questionnaire, designed specifically for IV therapy clinics, mobile IV hydration businesses, med spas, wellness clinics, and nurse-led practices.
This customizable intake form provides an organized way to collect important information before IV therapy, including medical history, surgical history, allergies, current medications and supplements, health conditions, hydration goals, symptoms, emergency contact information, and client authorization.

Perfect for practices that want a consistent, professional method for gathering patient health information as part of their intake and screening workflow.

WHAT’S INCLUDED
This IV Hydration Patient Intake Form includes sections for:
• Patient / Client Information
• Contact Information
• Date of Birth
• Emergency Contact Information
• Medical History
• Current Health Conditions
• Cardiac / Heart History
• Diabetes History
• Liver Conditions
• Kidney Conditions
• Thyroid Conditions
• Surgical History
• Allergy History
• Medication Allergies
• Current Medications
• Vitamins & Supplements
• Pregnancy Information
• Hydration Goals
• Current Symptoms
• Treatment Goals
• Additional Health Information
• Patient Authorization
• Signature & Date

The existing form specifically includes a medical-history checklist, surgical and allergy history, current medications and supplements, hydration goals, symptom tracking, and emergency contact and authorization information.

PERFECT FOR
• IV Hydration Clinics
• IV Therapy Businesses
• Mobile IV Therapy Providers
• Mobile IV Hydration Businesses
• Med Spas
• Medical Spas
• Wellness Clinics
• IV Infusion Practices
• Concierge IV Services
• Nurse-Led Wellness Practices
• Nurse Entrepreneurs
• Registered Nurses
• Nurse Practitioners
• Physicians
• Qualified Healthcare Providers
CREATE A PROFESSIONAL PATIENT INTAKE PROCESS
A standardized intake form can help your practice consistently collect important information from clients before treatment.
Use this template to help:

✓ Collect patient contact information
✓ Document relevant medical history
✓ Identify current health conditions
✓ Record surgical history
✓ Document allergies
✓ Record medications and supplements
✓ Collect information about hydration goals
✓ Document current symptoms
✓ Maintain emergency contact information
✓ Create consistent patient records
✓ Obtain patient authorization and signatures

MEDICAL HISTORY & HEALTH SCREENING
The template includes a detailed health-history section covering conditions such as cardiac, liver, kidney, thyroid, and other medical concerns.
This provides healthcare professionals with an organized starting point for gathering information that may be relevant to their clinical assessment.

The completed intake form should be reviewed by an appropriately qualified healthcare professional and should not be used by itself to determine whether a patient is medically eligible for IV therapy.

MEDICATIONS, SUPPLEMENTS & ALLERGIES
Keep important medication information organized in one place.
The form provides dedicated areas for documenting:

• Prescription Medications
• Over-the-Counter Medications
• Vitamins
• Supplements
• Medication Allergies
• Other Allergies
• Relevant Surgical History

This information can be incorporated into your practice's broader patient screening and documentation process.

HYDRATION GOALS & SYMPTOM TRACKING
The template also includes sections for documenting hydration goals and symptoms, allowing clients to provide additional information about why they are seeking services.
This makes the form useful as both an IV hydration intake form and patient health history questionnaire.

DESIGNED FOR CLINIC & MOBILE IV BUSINESSES
This form can be incorporated into the intake workflow for:
• Brick-and-Mortar IV Hydration Clinics
• Mobile IV Therapy Services
• Concierge IV Providers
• Med Spas
• Wellness Centers
• Vitamin Infusion Practices
• Nurse-Led Wellness Practices

CUSTOMIZABLE FOR YOUR PRACTICE
Personalize the template with your:
• Clinic or business name
• Logo
• Contact information
• Patient information requirements
• Medical history questions
• Health screening questions
• Treatment goals
• Provider information
• Practice-specific procedures

DIGITAL DOWNLOAD
This is a digital product. No physical item will be shipped.
Your purchase includes PDF and Word document formats, allowing you to customize the form for your practice or print it for patient use.

After purchase, download your files, customize the applicable sections, and incorporate the completed form into your patient intake and documentation workflow.

IMPORTANT MEDICAL DISCLAIMER
This template is provided for general administrative, informational, and documentation purposes only and does not constitute medical, legal, prescribing, regulatory, or compliance advice.
This intake form is not a medical evaluation, prescription, standing order, medical clearance, or determination that an individual is eligible for IV hydration therapy.

Patient screening, contraindications, treatment eligibility, treatment selection, medication or nutrient administration, dosing, monitoring, and other clinical decisions must be determined by appropriately qualified healthcare professionals in accordance with applicable laws, scope-of-practice requirements, approved clinical protocols, and medical oversight requirements.

Purchasers are responsible for reviewing and customizing this template according to their practice, services, patient population, privacy requirements, and applicable regulations.

Due to the nature of digital products, all sales are final.