Patient Intake Form

VitaLife Coastal Infusions

1. Patient Demographic Information

Full Name:

Date of Birth:

Gender:

Address:

City:

State:

Zip Code:

Phone Number:

Email address:

Emergency Contact Name:

Emergency Contact Phone Number:

SMS Communication & Marketing Consent:

I consent to receive SMS communications for appointment reminders and other important notifications.

I consent to receive marketing communications from VitaLife Coastal Infusions. I understand that I can opt-out at any time.

2. Allergy Information

Do you have any known allergies?

Yes No

If yes, please list them below:

Add Allergies

3. Past Medical History

Do you have any of the following conditions? (Please check all that apply

Diabetes

Hypertension

Heart Disease

Asthma

Chronic Pain

Kidney Disease

Liver Disease

Cancer

Other

If other, please specify:

Please list any surgeries or hospitalizations you have had in the past:

Add Surgery/Hospitalization

4. Past Family History

Do any of your family members have a history of the following conditions? (Please check all that apply)

Diabetes

Hypertension

Heart Disease

Cancer

Stroke

Mental Illness

Other

If other, please specify:

Please specify the family member and their condition:

Add Family member and their condition

5. Additional Information

Are you currently taking any medications?

Yes No

Add Medication

Do you have any other health concerns or information that you would like us to know?

6. Privacy Policy & HIPAA Compliance

I have been given the opportunity to read the privacy policy of VitaLife Coastal Infusions.

I understand that my information is stored and handled in a HIPAA compliant manner.

Your information will be encrypted.