New Client Medical Screening Form

First Name

Last Name

Date of Birth

Street Address

City

State

Email address

Phone Number

Do you have any medical allergies

No Medical Allergies

Yes, I have Medical Allergies (list below)

Allergy and Response

Prescription and OTC Meds

Client Privacy Consent

Privacy of your personal information is an important part of our organization. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

In this Office, Michael Kittle, RN, acts as the privacy information officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Do not hesitate to discuss our policies with any member of our office staff.

At Hydrations, LLC, we ensure that only necessary information is collected about you; we only share your information with your consent; storage, retention and destruction of you personal information complies with existing legislation, and privacy protection protocols, our privacy protocols comply with privacy legislation standards of our regulatory body and the law.

We will collect, use, and disclose information about you for the following purposes:

To deliver safe and efficient patient care

To ensure continuous high quality service
To assess your health needs
To advise you of treatment options
To communicate with other treating health care providers, including specialist and general physicians, referring physicians and/or locum physicians.
To enable us to contact and maintain communication with you, to book and confirm appointments.
To allow us to efficiently follow up on your treatment and on going care
To facilitate the billing process
To comply with legal and regulatory requirements according to the provisions of the regulated health professions Act and also to other regulatory and monitoring purposes.
To present individual cases for teaching and demonstrating purposes on an anonymous basis.

Our office will not, under any conditions, supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.

RELEASE, WAIVER, AND AGREEMENT NOT TO SUE

For purposes of this document (the “Release”), I understand that “Activity” refers to the activity of receiving an IV infusion, or intramuscular injection, or oral treatment and everything done in connection with it. I also understand that “Hydrations, LLC” refers to Hydrations LLC, MiDi Holdings LLC; all employees, officers, agents, and contractors.

I understand and appreciate that the Activity involves exposure to potential complications, including ones that I may not know about or anticipate, which may result in property damage, economic loss, bodily or mental injury, or death. I also understand that Hydrations, LLC may not be trained to care for problems that occur in connection with the Activity.

In consideration of being allowed to participate in the Activity, I agree that:b. Hydrations LLC is not responsible for my personal safety or the safety of my property as I participate in the Activity;My participation in the Activity is entirely voluntary;
My health does not preclude or restrict my participation in the Activity;

I have adequate health and hospitalization insurance and/or accept the financial responsibility for treatment should it become necessary;

Hydrations LLC has permission to authorize emergency medical treatment for me; and

Hydrations LLC has no responsibility for any injury that might occur in connection with that treatment.

Also in consideration of being allowed to participate in the Activity, I agree:

a. To fully assume all the risks and responsibilities of participating in the Activity;

b. To release, waive, and forever discharge any and all claims against Hydrations LLC for any injury to me or damage to m my property resulting from the negligence of Hydrations LLC or anyone else involved with the Activity; and

c. Not to sue Hydrations LLC or to seek any money from it or a judgment against it, for any injury to me or damage to my property resulting from the negligence of Hydrations LLC or anyone else involved with the Activity.

I acknowledge and represent that I have carefully read this Release and understand its contents and that I submit this form as my own free act and deed. I further state that I am at least:

eighteen (18) years of age
fully competent to agree to this Release
the consideration for submitting this Release is full and adequate.
It is my express intent that, while I am alive, this Release will bind me, my spouse, and the members of my family; and that in the event of my death, this Release will also bind my estate, heirs, administrators, personal representatives, and assigns.
I further agree that this Release will be construed under the laws of the State of Illinois, and if any provision of this Release is found to be invalid, the remainder of it will remain valid.

By submitting this form, you have agreed that you have given correct information to the best of your ability and that you acknowledge and agree to our Privacy Policy and Legal Waiver conditions.

Your information will be encrypted.