Intake - Vital Force IV Therapy

Vital Force Therapy & Wellness Intake Form

Step 1 of 6

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
Additional symptom
Additional symptom
Additional symptom
Additional symptom
Additional symptom

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 AGREEMENT:
This agreement between ("Patient'') and Vital Force Therapy & Wellness. Vital Force 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 Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In accordance with applicable state and Federal law.
2. I certify that the answers I provided to the health questions on the Health History laboratories 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 a medication.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effect related to my treatment to Vital Force Therapy & Wellness and discontinue use until advised to resume usage by my health care provider.
5. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
6. I understand that representatives of Vital Force Therapy & Wellness and/or Licensed Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of my treatment.
7. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by Vital Force Therapy & Wellness or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.
8. I agree that the Vital Force Therapy & Wellness/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 Therapy & Wellness will be in conjunction with the care provided by my current PCP.
9. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.
10. I have read and agree to the terms of this the Therapy Management Agreement.
11. I consent to text message appointment reminders. (Data rates may apply)
Signature
Date
MM slash DD slash YYYY
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 6

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

Consent & Form Submit

MEDICAL CONSENT AGREEMENT:

Vital Force (formerly Revive IV Therapy) | Birmingham AL

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