Intake - Vital Force IV Therapy

Vital Force Therapy & Wellness Intake Form

Step 1 of 7

Your Information
Please be sure to complete ALL REQUIRED FIELDS that are marked with an * asterisk. Otherwise you will see an error, and have to start the entire form over again.
Please list current symptoms & concerns prompting your visit
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Patient Information
FIRST NAME
MIDDLE NAME
LAST NAME
NICKNAME
ADDRESS
CITY
STATE
ZIP
HOME PHONE:
MOBILE PHONE:
EMAIL ADDRESS:
DRIVERS LICENSE NUMBER (copy required on checkin)
OCCUPATION:
HOURS PER WEEK:
REFERRED BY:

Consent & Form Submit
Please be sure to complete ALL REQUIRED FIELDS that are marked with an * asterisk. Otherwise you will see an error, and have to start the entire form over again.
MEDICAL CONSENT AGREEMENTS:
IV Infusion/Treatment Management Agreement This therapy management agreement between (Patient) and Vital Force Anti-Aging, LLC establishes guidelines and conditions that are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution. Patient agrees and accepts the following conditions:
1. I understand that the vitamins/medications that I am receiving are based on a diagnosis derived from my submitted medical history, physical examination and results of current lab work. Medications are to be used exclusively for treatment of medical conditions in accordance with applicable State and Federal laws.
2. I certify that all current health and health history answers provided are accurate to the best of my knowledge. I attest to the fact that I have not been coached by a third party nor have I knowingly been deceptive for secondary gain when receiving medical treatment or prescription medications.
3. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse reactions believed to be directly related to IV therapy. I voluntarily assume any and all possible risks which may be associated with IV therapy.
4. I understand that representatives of Vital Force, a licensed physician or another licensed medical professional are available for questions/concerns during normal business hours throughout the course of my treatment.
5. I certify that I have no known diabetes, congestive heart failure or any other heart disease.
6. I understand that IV hydration therapy is not covered by health insurance. I agree that all services and medications provided by Vital Force or its’ associated providers are private pay and will be paid before services/products are distributed. Vital Force will not seek reimbursement through my health insurance company, Medicare, Medicaid or other third-party payer.
7. I understand that the Vital Force hydration lounge/physician relationship is not intended to replace the existing relationship with my current primary care physician. Treatments provided by Vital Force Rx will be in conjunction with the current treatments provided by my current PCP.
8. I understand that Vital Force will not be responsible for any IV infusions that are stopped mid-drip.
9. I understand that I will be receiving an IV infusion that may contain any combination of the following: Ascorbic Acid, Methylcobalamin, Magnesium Sulfate, B-Complex, Trace Minerals, BCAA’s, Glutathione, Zofran, Toradol, Reglan, Carnitine, Arginine, Phosphatidylcholine, Methionine, Inositol, Choline, Chromium and EDTA.
10. I agree that if I have any allergies to any above listed ingredients, I will make the Vital Force Rx staff aware.
11. I agree that I will use my medications only as prescribed and will keep them in the original, labeled containers.
12. I agree that some vitamins including Methylcobalamin, B Complex, Amino Acids, etc are made with preservatives including Benzyl Alcohol, etc
13. I consent to text message appointment reminders. (Data rates may apply)
HRT Management Agreement This agreement between (Patient) and Vital Force Anti-Aging LLC establishes guidelines and conditions for the use of hormone replacement therapy (HRT) involving DEA controlled or scheduled medications. Vital Force Rx and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution. The patient agrees and accepts to the following conditions:
1. I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, and the results of lab work and a physical examination. The medications are to be used exclusively for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and Federal law.
2. I understand and agree that no medical treatment or medication provided to me by Vital Force will be used for the purposes of bodybuilding, performance enhancement or physical appearance.
3. I certify that the answers I provided to the health questions on the health history are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of medication.
4. I will not attempt to obtain HRT medications from any other health care practitioner without disclosing my current usage of HRT or other medications. I understand that it may be against the law to do so.
5. I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side effect related to the use of my HRT to Vital Force and discontinue use until advised to resume by an authorized physician. I voluntarily assume any and all possible risks which may be associated with HRT.
6. I understand that representatives of Vital Force and/or a licensed medical professionals are available for questions and/or concerns during normal business hours throughout the course of my treatment.
7. I agree that the HRT medications furnished by Vital Force are for my personal use only and for no other purpose. I will not share, sell, or trade my medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
8. I will be able to purchase the medications from the pharmacy designated by Vital Force and the pharmacy will send medication directly to me. I understand that I have the right to purchase my medications from any pharmacy of my choice. If I chose to obtain medications from a pharmacy outside of the designated provider, I must notify Vital Force in writing of my intention to do so and include the name of the pharmacy in my request.
9. I agree and understand that federal regulations prohibit the return of prescribed medications.
10. I agree that the Vital Force patient/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Vital Force will be in conjunction with the care provided by my current PCP.
11. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
12. I understand that Vital Force only uses HRT to treat patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current health history through either patient’s personal physician or a licensed healthcare provider in the Vital Force clinic. Agreeing to lab work does not automatically qualify patient for clinical necessity and prescription of HRT.
13. I understand that should I choose to opt out of therapy with Vital Force, all of my prescriptions will be cancelled through the pharmacy and will not be transferred to any other pharmacy.
14. This Therapy Management Agreement is a binding contract for a minimum of 4 consecutive months. If you choose to cancel your membership prior to the 4 month commitment you will be responsible for the payment of the remainder of your 4 month commitment. (IE: Used HRT 1 month, then cancel = responsible for 3 remaining months).
15. Vital Force IS NOT RESPONSIBLE for any lost packages or medications not received from the pharmacy. If the package must be replaced, I understand that I must report to Vital Force that it was not received and I will pay the replacement fee.
16. Please Check To Agree*(Required) - If not checked this form will not submit and you will have to start over
  - Select All
  - I hereby certify that I have read and agree to the terms and conditions of this therapy management agreement.
  - I have read and fully understand clause #1 through #14 on this agreement and by signing below I agree that Vital Force Anti-Aging, LLC has permission to charge my account, should I choose to opt out of the hormone replacement therapy program, I acknowledge my card will be charged the full three month amount accordingly.
  - Vital Force Anti-Aging LLC cannot issue refunds for any services rendered or any products purchased once payment is processed. An in clinic credit may be available at Clinic Director's discretion.
17. Signature
18. Date
  MM slash DD slash YYYY
19. Marketing Agreements
  Here at Vital Force Therapy & Wellness, we like to stay in touch with our current and potential patients via e-mail, text messages, and social media. We would love to have you involved but understand the hesitation. Please read and mark the options below if you are uninterested in these marketing approaches.
  - I would like to OPT OUT of promotional e-mails and text messages.
  - I do NOT agree to having my photo posted on social media for promotional postings.

Vital Force Therapy & Wellness Intake Form

Step 1 of 7

Your Information

Patient Information

More About You

More About You (Continued)

Personal & Family History

Hormone Questionnaire

MALE HORMONE QUESTIONNAIRE:

FEMALE HORMONE QUESTIONNAIRE:

SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY

MEDICAL RELEASE FORM

PLEASE RELEASE MY RECORDS FROM:

TO: VITAL FORCE ANTI-AGING, LLC (DR. GARY RUSSELL, MD)

Consent & Form Submit

MEDICAL CONSENT AGREEMENTS:

Vital Force (formerly Revive IV Therapy) | Birmingham AL

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