Please enable JavaScript in your browser to complete this form.PATIENT DETAILSDate *Patient Name *FirstLastDate of Birth *Sex *MaleFemaleEmail *Cell Phone NumberCan we text you?YesNoHome Phone NumberWork PhoneCan We Leave a Detailed Message?HomeCellWorkPlease tick all that applyMailing Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPatient Current or Previous Occupation *Marital Status *SingleMarriedDivorcedWidowedReason For Appointment *EMERGENCY CONTACT INFORMATIONEmergency Contact's Name *FirstLastContact Number *Relation to Patient *Pertinent Medical History (Including hospitalizations/surgeries) *Please List All medications including prescriptions, over the counter, vitamins, herbs and homeopathic you are taking. Please specify dosage. (If none, please write NA) *Please list any allergies to medications or food (If none, write NA) *In the event a family member(s) or caregiver(s) attends my visit(s) and is in the exam area at the time of my evaluation and/or treatment, I give ELITE IV PLLC, its providers, and employees my permission to discuss freely care with that person(s) present.YesNoI understand that intravenous therapy and any claims made about these infusions have not been evaluated by the U.S Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any medical disease. Infusions are not a substitute for your primary physician’s medical care. For today’s procedure: 1. I understand that intravenous infusion involves the insertion of a needle into a vein and injection of the prescribed solution. 2. I understand possible alternatives to IV Therapy include but are not limited to oral supplements and/or dietary and lifestyle changes. 3. I understand the risks of IV Therapy include but are not limited to: a) Occasional discomfort, bruising, and possible pain at the injection site b) Rare inflammation of the vein used during the infusion, phlebitis, and metabolic disturbances. c) Extremely rare allergic reactions, anaphylaxis, infection, cardiac arrest and death. 4. I understand other unforeseen complications could occur. 5. I do not expect the Elite IV, PLLC to anticipate and/or explain all risks and possible complications of intravenous infusions. 6. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered. 7. I understand I have the right to consent to or refuse any proposed/offered therapy, at any time prior to its administration. By signing below, I acknowledge that I have been provided access to a copy of ELITE IV, PLLC’s Notice of Privacy Practices. I understand the information provided on this form and agree to all statements made above, all procedures have been adequately explained to me, and I authorize and consent to the performance of procedures. I release ELITE IV, PLLC including its providers and employees from all liabilities from any complications or damages associated with intravenous infusion therapy. I acknowledge that I have been provided access to a copy of ELITE IV, PLLC's Notice of Privacy Practices.YesNoFINAL STEPSHow Did You Hear About Us?Internet/Search EngineFriend ReferalSocial MediaReferralTV/RadioThird-Party ReviewOtherIf other, please specifyAdditional Questions or CommentsSubmit