New Patients

Patient Assessment Form

"*" indicates required fields

Patient Information

First Name*

Last Name*

Email*

Phone*

Date of Birth*

Drug Allergies*

Current Medications*

(include any conditions for which you are being or have been treated):

Medical History*

(include any conditions for which you are being or have been treated):

How Did You Hear About Us?

Patient Consent*

I agree to the following:

Thank you for choosing IVs in the Keys to provide you with our medically designed rehydration therapy. It is our goal to provide you with the best treatment available in a safe and comfortable manner. In doing so we have established a set of protocols that identify higher risk patients that may require and benefit from a higher level of medical care. Due to these protocols, and to ensure maximum patient safety, some clients may not be eligible to receive IVs in the Keys therapy. We thank you for your understanding in this matter. By signing below, you certify that you understand and agree with the following statements.
– I have read and understand the medical disclaimer.
– All the information I have provided in my medical screening is complete and accurate to the best of my knowledge.
– I understand that, while receiving my treatment, I will not be able to leave the direct supervision of IVs in the Keys staff, including the restroom. If I need to use the restroom, I will alert an IVs in the Keys team member and they will assist me.
– I understand the risk of IV insertion may include: pain, bleeding, bruising, blood clots, infection, and local soft tissue damage. While I understand that these side effects are rare, they may occur, and I understand to seek immediate medical attention if such complications arise
– I certify that I am at least 18 years of age and have provided photo ID if asked to present it.
– I understand that not all people react the same way to medications and treatment and that while most feel better after therapy, there is no guarantee that I will feel the same way.
– I understand that the IVs in the Keys team has the right to refuse or terminate my treatment at any time for any reason and that I must comply with their instructions while receiving treatment.
– I certify that I am not intoxicated or under the influence of any mind-altering substances at the time of therapy.
– I understand that IVs in the Keys, for staff and customer safety, is under constant video surveillance.

Legal Consent For Electronic Signature*

I agree to the terms and conditions.

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

Today's Date*

Patient Signature*

Physicians Only

Is the Medical Assessment within normal limits?

Yes

Is patient suitable for treatment?

Yes

Physician Orders

Today's Date

Physician Signature

Waiting for another signer

Comments

This field is for validation purposes and should be left unchanged.

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