Patient Intake Form

Welcome to Be Alive LLC! The following patient intake form is essential for gathering necessary data to facilitate your infusion treatment. By completing and submitting the form below, you provide consent to Be Alive LLC to access and retain this data for treatment purposes. We appreciate your cooperation and look forward to providing you with the best care possible.

Patient Intake Form

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Name *

First

Last

Date *

Date of Birth *

Age *

Sex *MaleFemalePrefer Not to Say

Full Address (Street, City, State, Zip) *

Phone Number (Must include area code) *

Email *

Emergency Contact 1 (Name / Phone Number) *

Emergency Contact 2 (Name / Phone Number) (copy)

Why would you like to receive IV therapy? *

Have you ever received IV therapy before? *YesNo

If yes, were there any complications or issues we should know about prior to treatment? (If no, put N/A) *

Please Check if you have any of the following conditions IV therapy can help with: *

• Fatigue
• Low Immunity
• PMS
• Anemia
• Fertility Prep
• Weight Issues
• Migraines
• Asthma
• Allergies
• Stress
• Low Depressed Mood
• Digestive Issues
• Aging
• IBS/Inflammatory Bowels
• Sleep Disorders
• Irritability/Moodiness
• Muscle Spasms
• Numbness/Tingling of Body
• None

Please list all allergies known or suspected: *

Please list all prescription drugs and/or supplements you are taking and doses: *

Date of last Physical Exam/Blood Test *

Any abnormal results on blood test? If yes, please describe: *

Please check if you've had any diagnosis of the following *

• High Blood Pressure
• Low Blood Pressure
• Arrhythmia
• Diabetes
• Cancer
• Sudden Weight Loss
• Angina
• Abnormal EKG
• Bleeding Disorder
• Ankle Swelling
• MI/Heart Attack
• Asthma
• Congestive Heart Failure (CHF)
• Anxiety
• Kidney Disease
• Adema
• G6PD Deficiency
• None

Please note if you have any health condition not listed above:

By typing your name in the box below, you are giving your consent to receive therapy services from Be Alive LLC. Please note that this consent is required for us to provide you with our services. *

Submit