About this template
Streamline patient intake for your wellness clinic or medical practice with this comprehensive IV Hydration Therapy Enrollment Form template. Designed specifically for healthcare providers, nurses, and wellness practitioners, this form collects critical patient information before administering treatments, ensuring safe and personalized care.
The form securely captures essential personal details, emergency contacts, current medications, allergy histories, and specific medical conditions like pregnancy status. It also includes vital consent acknowledgements and digital signature capture to maintain compliance and liability standards before your client's first infusion session.
Whether you operate a boutique IV lounge, a medical spa, or an integrative health clinic, this template helps you eliminate messy paper clipboards and manual data entry. With Doc2Form, you can instantly transform this layout into a ready-to-use Google Form, share it via email or SMS link prior to appointments, and keep all patient health records neatly organized in your connected Google Drive.
Key features
- Collect comprehensive patient health history and current medication lists in one step.
- Screen for critical contraindications including pregnancy and severe allergies.
- Secure digital consent acknowledgements and liability waivers before treatment.
- Easily embed on your clinic website or text to clients ahead of their appointment.
- Automatically store and organize all patient responses in a secure Google Sheet.
Use cases
Boutique IV hydration lounges onboarding new wellness clients.
Medical spas screening patients for vitamin infusion and recovery drips.
Mobile IV therapy providers collecting intake forms remotely prior to…
Mobile IV therapy providers collecting intake forms remotely prior to house calls.
Integrative medicine clinics tracking patient health status and treat…
Integrative medicine clinics tracking patient health status and treatment history.
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Date of Birth (Date)Please enter your birth date.
- Phone Number (Short answer)Enter the best phone number for appointment confirmations and reminders.
- Email Address (Short answer)We will send your appointment details and intake confirmation here.
- Home Address (Paragraph)Enter your current residential street address, city, state, and zip code.
- Emergency Contact Name (Short answer)Provide the full name of a family member or trusted friend we can contact in case of an emergency.
- Emergency Contact Phone Number (Short answer)Enter the phone number for your emergency contact.
- Medical History & Conditions (Checkboxes)Select any current or past medical conditions that apply to you.
- Current Medication Status (Multiple choice)Are you currently taking any prescription medications, blood thinners, or daily supplements?
- Medication List (Paragraph)If you answered yes above, please list all medications, dosages, and supplements you are currently taking.
- Pregnancy Status (Multiple choice)Are you currently pregnant or breastfeeding?
- Allergy Status (Multiple choice)Do you have any known allergies to medications, adhesives, latex, or specific vitamins (e.g., Sulfa, B-complex)?
- Allergy Details (Paragraph)If you have any allergies, please list them and describe your typical reaction.
- Consent and Liability Acknowledgement (Multiple choice)Please review and confirm your understanding of the treatment risks, benefits, and voluntary nature of IV hydration therapy.
- Client Signature (Short answer)Please type your full legal name here to serve as your digital signature authorizing this treatment.
- Signing Date (Date)Select today's date.
FAQ
How do I send this enrollment form to my patients?
Once you convert this template into a Google Form using Doc2Form, simply copy the form link and send it via email, SMS, or embed it directly on your clinic's booking website so patients can complete it before arrival.
Can I customize the medical questions to fit specific vitamin infusions we offer?
Yes! Google Forms are fully customizable. You can easily add, remove, or edit questions to match your clinic's specific IV drip options, protocols, and intake requirements.
Where is the patient health data stored?
All patient submissions are securely saved in your personal Google Drive and automatically populated into a linked Google Spreadsheet for quick review by your medical staff.
Is this template free to use?
Yes, this template is completely free to convert and use via Doc2Form and Google Forms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.