Client Intake Form Name * First Name Last Name Date MM DD YYYY Time Hour Minute Second AM PM Blood Pressure Lung Sounds Heart Rate INFUSION/INJECTION DETAILS Nutrient IV Drips The LiquiLift Fountain of Youth Performance Hydration Natural Defense Rise and Shine The Executive Glutathione Chelation Therapy Price Discount Total Package # Reason for Discount Injections Vitamin B-12 Vitamin B-Complex Vitamin D3 Lipotropic MIC B-12 Custom to client infusion IV Site Catheter Size # of Attempts Fluids (mls) IM Site IM mls Complications Provider Name Provider Initials Vial Name / Lot # / Expiration 1. 2. 3. 4. 5. 6. 7. 8. IV Solution / Lot # / Expiration 1. 2. Thank you!
