EmailMe Form - CLIENT INTAKE AND CONSENT FORM

Name *

First Last

Email Address *

Phone *

### - ### - ####

Are you 18+ years old? *

Yes

No

Please Select the following discounts that may apply:

How did you hear about us?

Do you have any of the below health conditions or concerns?

Are you taking any controlled substances? *

Yes

No

Are you on any Antidepression(SSRI) or Anxiety Medications? *

Yes

No

Do you drink alcohol? *

Yes

No

Are you allergic to any of the products listed on our websites?(www.driptherapi.com/www.nadplus1.com) *

Yes

No

List allergies here:

Desired location of Service:

In Spa Service (Shelby Township) 14202 Lakeside Blvd N. Shelby Charter Township

In Spa Service (Macomb) 8152 25 Mile Road, Suite B, Macomb

In Spa Service (Southfield) 19315 W. 10 Mile Rd, Southfield

Mobile Service (Home - Office - Event) $50+ Fee

NAD Plus, Inc. Shelby Township

Online Order via Tele-Med

Other

Desired Date and Time of your appointment. Please note that you must remit $25.00 to secure the selected date. You will be forward to our payment center upon completion of this form. Thank you for choosing Drip Therapi.

MM / DD / YYYY HH : MM AM/PM

Check the desired Intramuscular Injection(s)

Do you have any COVID-19 symptoms or have been diagnosed within the last 30 days? *

Yes

No

What is your reason for your therapy visit? *

Do you take any Blood Thinners? *

Yes

No

Are you booking any of our enhanced services that may require more the our typical 60-minute infusion time? (e.g. NAD+ or High Dose Vitamin C)

Yes

No

List any Medication that you think would cause any concerns for your IV Therapy: please type none if there is none *

List any Vitamins or Herbal supplements you take:

Address (if using Mobile Concierge Services)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

I understand that the service that I will receive is for the purposes of nutrition, vitamins, and hydration therapy. I agree to the terms and conditions of Drip Therapi. These procedures may be performed by a physician(s), nurses, technicians, physician assistants, or other healthcare professionals employed by Drip Therapi. More importantly, procedures will be performed by a trained intravenous or intramuscular professional. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, you can consult with your primary care physician(s) or similar to provide you with additional information about IV Hydration Therapy. You also understand that your physician may ask you to sign additional Informed Consent documents relating to specific procedures. Anytime an injection is given, there is potential for pain, bruising, or swelling at the injection site which is normally minimal. These reactions are fairly mild and self-limited and usually resolve within 24-48 hours. Rare allergic reactions to the injection or infusion may occur, but rare. It is important that you inform the health care professional or proceed to the nearest emergency room if you experience severe side effects such as difficulty breathing, lips swelling, hives, and chest pain. Healthcare professionals cannot guarantee any specific result(s) of any therapy. Please do your own research about vitamin IV Hydration Therapy. You should know about any allergies that you may have to our listed products before taking in our therapy. I release the Drip Therapi staff or affiliates, its physicians, and/or healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of Drip Therapi or its employees. I understand that Drip Therapi’s Staff involved in my therapy will rely on this form, as well as other information provided by me, my immediate family, or others who have information about me in determining whether to perform or recommend therapy procedures. We recommend, but not require; that you do a lab study on your blood, to see what vitamin and nutrition you are deficient in via your primary care physician. I agree that I have provided accurate and thorough information regarding this form and any conditions or events that may impact decision-making into receiving this therapy. In return for services to be provided by Drip Therapi, I agree to pay for services rendered by Drip Therapi to me or for my benefit. I agree to pay in full for such services rendered at the time of my appointment or before. By signing this document, I certify that I have read and understood the contents of this form that the information provided by me is accurate, and that any questions or concerns have been answered to my satisfaction. I believe I have adequate information and knowledge upon which to base an informed consent to the proposed therapy procedures; that are offered by Drip Therapi. I am aware of the potential risks involved as outlined. Any and all (a) content or statements appearing on this site haven’t been evaluated by the Food and Drug Administration, (b) product or related claims and provisions aren’t intended to diagnose, treat, cure, or prevent any disease, (c) content or statements appearing on this site aren’t intended to substitute for professional medical advice. More importantly, the material displayed on our website and this form is provided for informational purposes only, the designation, reference, or use of the word therapy is used for marketing purposes only and is not medical advice. All therapies are specific formulations prepared by Drip Therapi or Drip Therapi Macomb, and individual client results will vary. Checking yes on this paragraph will act as your signature and verification that you have read and answered all the questions on this form honestly. Please note that there is a $25.00 Appointment Fee to secure your appointment time; that is non-refundable. The $25.00 will be applied towards your services. Please click the SUBMIT button to be routed to our payment center.

Thank you and we are looking forward to assisting you. *

Yes

No