INFZD — Patient Intake Form

1 · Patient Information

First Name *

Last Name *

Date of Birth *

Age

Biological Sex *

Phone Number *

Email Address *

Home Address

City

State / ZIP

2 · Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

3 · Infusion Selection

Select the infusion you are booking for today's session:

The Everyday Hero Vitamin & Nutrient Blend

The Reset Button Recovery & Rehydration Blend

The Shield Immune Support Blend

The Champion Performance & Recovery Blend

PICO Infusion CBD Infusion

Reason for visit / wellness goal today

4 · Medical History

Do you have or have you been diagnosed with any of the following? (Check all that apply)

If other, please describe

Have you ever had an adverse reaction to an IV infusion?

Yes No

Have you been hospitalized in the last 12 months?

Yes No

Have you had any surgeries in the last 6 months?

Yes No

5 · Current Medications & Supplements

Are you currently taking any prescription medications?

Yes No

Are you currently taking any vitamins or supplements?

Yes No

Please list all current medications and supplements (name, dose, frequency)

6 · Allergies

Do you have any known allergies to medications, vitamins, or supplements?

Yes No

Do you have any food allergies or sensitivities?

Yes No

Do you have a latex allergy?

Yes No

Please list all known allergies and describe your reaction

7 · Lifestyle & Current Symptoms

Are you currently pregnant or breastfeeding?

Yes No

Have you consumed alcohol in the last 24 hours?

Yes No

Have you eaten or had fluids in the last 4 hours?

Yes No

Are you currently experiencing any illness or infection?

Yes No

Do you currently have a fever?

Yes No

Rate your current hydration level:

Very Dehydrated Somewhat Dehydrated Neutral Well Hydrated

Current symptoms (check all that apply):

8 · PICO CBD Infusion — Additional Screening

Complete this section only if you selected the PICO CBD Infusion above.

Do you currently use any CBD, THC, or cannabis products?

Yes No

Are you subject to drug testing (employment, legal, or otherwise)?

Yes No

Have you ever had a reaction to CBD or cannabis products?

Yes No

Are you currently taking any blood thinners or anti-seizure medications?

Yes No

If yes to any above, please explain

9 · Informed Consent & Authorization

Full Legal Name (typed signature) *

Today's Date *