Drip Factor Patient Intake

01

Patient Information

Basic details we'll use to confirm your identity and reach you about your appointment.

Full legal name *

Date of birth *

Sex assigned at birth * Used only for clinical screening purposes.

Height (in) *

Weight (lb) * Helps your clinician determine the right infusion rate and volume.

Mobile phone *

Email *

Visit address *

Emergency contact name *

Emergency contact phone *

Referring provider (optional)

02

What Brings You In

Tell us what you're interested in so your clinician can confirm it's the right fit before your visit.

03

Health History

These conditions can affect whether IV therapy is safe for you, or change which drip and infusion rate your clinician recommends.

Are you currently pregnant or breastfeeding? *

Pregnant Breastfeeding Neither N/A

Anything else about your health history we should know? (optional)

04

Allergies & Medications

Allergy history is one of the biggest factors in infusion safety — please be thorough.

Do you have any known allergies? Select all that apply. *

Vitamins or mineralse.g. B12, glutathione, magnesium Other medications Latex Adhesive or medical tape Food allergies No known allergies

If you selected any allergy above, list the specific substance and reaction

Current medications & supplements *

05

Prior IV Therapy

Let us know about any past infusions or injections so we can avoid an ingredient that's given you trouble before.

Have you received IV vitamin therapy before? *

Yes No Not sure

A prior hypersensitivity reaction doesn't automatically rule out treatment, but it changes how your clinician premedicates and monitors you. Please describe it as precisely as you can.

06

Recent Labs (optional)

If you have recent bloodwork (CBC, metabolic panel, vitamin or mineral levels) that's relevant to why you're coming in, feel free to upload it here — it helps your clinician tailor your drip, though it isn't required for most visits.

Drop lab files here, or click to browse

PDF, JPG, PNG, or HEIC · up to 15 MB each

Date these labs were drawn (if known)

Anything we should know about your labs? (optional)

07

Consent & Signature

Please read carefully before signing.

By signing below, I acknowledge that:

I understand IV therapy carries a small risk of allergic reaction, including rare severe (anaphylactic) reactions, as well as bruising or infiltration at the IV site, vein irritation, lightheadedness or fainting, nausea, and headache. I understand this infusion will be administered in person by a licensed clinician under physician medical oversight, using sterile, single-use equipment, and that a clinical screening is performed immediately before treatment begins. I have answered every question in this form completely and accurately to the best of my knowledge. I understand my clinician may contact me for more information or to reschedule if a drip isn't appropriate for me right now, and that I may withdraw consent at any point before or during treatment.

Type your full legal name as your signature *

Your signature preview will appear here

Date *

A quick check-in before we begin.