IV Therapy Intake Form Patient First Name(Required) Patient Last Name(Required) Cell Phone(Required)Address(Required)Email(Required) Age(Required)Date of Birth(Required) MM slash DD slash YYYY Pronouns(Required) Emergency Contact(Required) Phone(Required)Relationship(Required) How did you hear about us or whom may we thank for referring you?(Required)What is your primary health concern(Required)What IV treatment are you interested in?(Required) Wellness Glutathione Iron High Dose Vitamin C Other Other Have you received IV therapy in the past(Required) Yes No Any complications from blood draws or IVs?(Required) Yes No Yes Are you currently under the care of a physician? (If yes, whom and for what are you being treated for?)(Required) Yes No Yes When was your last blood work completed? CBC (Date) MM slash DD slash YYYY CMP (Date) MM slash DD slash YYYY Iron Panel (Date) MM slash DD slash YYYY **Please attach results when applicable. Drop files here or Select files Max. file size: 256 MB. Do you have a history of any of the following? If yes, please explain.Heart disease Kidney disease Liver disease Low blood pressure Syncope Anaphylaxis Please list any current prescriptions, supplements or over the counter medications you are currently taking:ListMedication or SupplementFor?Dose Add Remove Policies and Consents By voluntarily signing this document, I show that I have been provided the clinic policies and consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Check each box belowHIPAA Notice of Privacy Practices(Required) I acknowledge that I received a copy of Amber Wellness Group clinic policies, as well as, HIPAA privacy laws and I agree to the use of my medical information for my treatment. Financial Responsibility(Required) I understand that I am responsible for full payment of services and supplements at the time of service. If you do not have insurance or your provider is out of network with your insurance, we offer you a 20% discount on the office visit charge. (We encourage you to bill your own insurance, please ask us how we can help). Insurance Billing(Required) I understand that I am responsible for completing the insurance verification form and know that I am responsible for payment for any non-covered services denied by my insurance company. If you request us to bill your out of network insurance you agree to pay for the entirety of the charges billed and not covered by your insurance and you will not be granted the 20% discount that is offered at time of service. Roles and Responsibilities for Provider and Patient(Required) I understand that my provider will only prescribe medications that they believe are in my best interest and it is my responsibility to keep them informed of any changes or updates in my health or outside medications. Labs Review(Required) I accept that any labs ordered by my provider requires a follow up appointment for review and interpretation to establish an appropriate treatment plan. Prescription Refill Policy(Required) I accept responsibility to call my pharmacy when I need a refill on my pharmaceutical medications, even if I am out of refills. The clinic will respond to all refills within 48 hours of receiving notice from the pharmacy. Supplements(Required) I understand that refills on my supplements should go through the front office to verify availability, or I can use the clinic’s online dispensary through Fullscript. Supplements purchased from the clinic are non-refundable. Cancellation Policy(Required) I understand that it is my responsibility to know when my appointment is and that reminders from the clinic are a courtesy. Failure to notify the clinic 48 hours prior to my appointment, for either a cancellation or rescheduling, or missing my appointment entirely will result in a $140 fee. E-consult Policy(Required) I understand that the patient portal is where my provider will communicate with me as it is the most secure platform. Any messages that I send that go beyond simple clarification may be subject to an e-consult fee. By signing below: I acknowledge that I have been provided ample opportunity to read the HIPAA Notice of Privacy Practices provided by the clinic or that it has been read to me. I understand all of the above and give my oral and written consent to evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment. I agree that I will consult the consent form or call the office for clarification when I have concerns regarding my care at Amber Wellness Group. SignatureDate MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
