Medical Intake Form

Medical Intake Form

This form is required for all new clients to Arrive Health and Wellness seeking Vitamin Injection, IV and/or Peptide Therapy.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*
Gender*
Contact Number*
Format: (000) 000-0000.
Email Address
I am currently being treated in the State of: *
Please select your Arrive provider:*
What are your chief complaints and/or reasons for seeking treatment?:*

Alcohol Related IllnessDigestionAthletic PerformanceDifficulty ConcentratingBrain FogFacial Wrinkles/LinesCold SymptomsFatigueDehydrationFlu SymptomsDepressionFrequent IllnessHair/Skin/Nail HealthHeadache/MigraineLow EnergyLow MoodMalabsorptionNauseaNutrient DeficiencyStressWeight LossOther
Have you been diagnosed with or currently have:*

DiabetesHypertensionCardiac diseaseCardiomyopathyCongestive Heart FailureAtrial FibrillationGI BleedingStomach Ulcers or GastritisRenal Failure or Renal InsufficiencyLiver DiseaseHistory of CancerActive CancerPsychiatric disorderBipolarHemophiliaG6PD DeficiencyHIV/AIDSNone of the followingOther
Please explain:*
Please list all current and past medical diagnosis. If none, please indicate "None": *
Are you currently:*

PregnantTrying to get pregnantOn Birth ControlBreastfeedingAn active InfectionNone of the following
Are you currently taking any medication?*

YesNo
Please list them:*
Are you currently taking any of the following?*

AntibioticsNSAIDsBlood ThinnersChemotherapyCorticosteroidsDigoxin/LanoxinInsulinImmunotherapyDiureticsNone of the followingOther
Do you have allergies or sensitivities to:*

Alcohol Based ProductsCobalaminCobaltLatexSulfaNone of the following
Do you have any allergies to food or medications?*

YesNoNo Known Allergies
Please list them.*
If there is anything else you'd like the our Medical Team to know, please let us know here?
I affirm the above information is accurate to the best of my knowledge. I acknowledge that Arrive Health and Wellness is not responsible for any errors that may occur as a result of any omissions or incorrect information on this form. *
Date*

MonthDayYear
Date

My Products*

Medical Evaluation

At Arrive Health and Wellness, a thorough medical evaluation is required by one of our mid level practitioners prior to receiving treatment. This evaluation includes a comprehensive review of your medical history, current health conditions, and any relevant symptoms to ensure you are a candidate and that you receive the most appropriate and effective treatment. Our goal is to tailor a personalized treatment plan that addresses your unique health needs and promotes your overall well-being.

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