Name
Gender
List any current or past medical conditions (e.g., heart disease, diabetes, etc.).
List all medications, including dosage and frequency.
Specify any known allergies, including medications, foods, or other substances.
Provide details on any surgeries the patient has undergone.
Specify the type of IV therapy requested (e.g., hydration, vitamin infusion, etc.).
Indicate how often you plan to receive IV therapy sessions.
give your consent for treatment
Pregnant or Breastfeeding?