IV Hydration Therapy Intake Form
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IV Hydration Therapy Intake Form
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The IV Hydration Therapy Intake Form is purpose-built for IV hydration clinics, mobile IV therapy services, and wellness infusion bars that administer intravenous fluids, vitamins, and nutrient cocktails. This IV vitamin drip intake form captures the essential health screening data that nurses and providers need before starting any infusion: patient demographics, vital signs baseline, hydration status assessment, kidney and liver function history, and a thorough contraindication checklist covering conditions like congestive heart failure, renal insufficiency, and electrolyte imbalances that could make IV therapy unsafe.
Designed to streamline the mobile IV therapy patient form workflow, this template includes a complete allergy assessment with specific screening for common IV additives (B vitamins, glutathione, magnesium, zinc, vitamin C, NAD+, biotin), current medication review to identify potential interactions (diuretics, blood pressure medications, blood thinners), and a symptom assessment that helps providers recommend the appropriate drip package -- whether it is basic hydration, immune boost, athletic recovery, hangover relief, beauty drip, or a custom vitamin cocktail. The integrated payment field allows clinics to collect session fees or package pricing at the time of intake.
Every field is HIPAA-compliant and optimized for the fast-paced IV therapy environment where patients expect quick onboarding. The built-in consent agreement covers the risks specific to IV infusion including bruising, vein irritation, infiltration, allergic reaction, and air embolism. Patients can complete this form on their phone before a mobile IV appointment or on a tablet at the drip bar, reducing wait times and ensuring providers have the clinical information they need to deliver safe, effective IV hydration therapy.
What's included
- Patient demographics and contact information
- Hydration status and symptom assessment
- Contraindication screening for IV infusion safety
- Allergy assessment with IV additive-specific screening
- Current medication review for interaction checking
- IV drip package selection with add-on boosters
- Integrated payment collection for session fees
- IV therapy-specific informed consent with e-signature
- Structured medication list with dosage and frequency tracking
- Emergency contact information
- Allergy documentation with severity levels
- Medical conditions checklist
Who uses this template
- Mobile IV hydration therapy services and concierge IV providers
- IV vitamin drip bars and wellness infusion lounges
- Med spas and aesthetic clinics offering IV nutrient therapy
- Athletic recovery and sports performance IV clinics
All form fields
14 fields across 2 pages. Customize any field after signing up.
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