On the Move Mobile IV and Medical

On the Move Mobile IV and Medical

Consent for IV Hydration Service & Scheduling
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How did you hear of On the Move Mobile IV and Medical?*

Google searchYoutubeTV commercialFriend or family memberSocial MediaFlyerConferenceOther
Promo code
If known, what IV Hydration are you wanting?
What date are you requesting to schedule your first visit?

MonthDayYear
Date
What timeframe for the date above works best for you?

Between 8-10 AMBetween 10-12 PMBetween 12-2 PMBetween 2-4 PMBetween 4-6 PMBetween 6-8 PM
Gender

FemaleMaleTransgenderI choose not to answerOther
Ethnicity

White or CausasionBlack or African AmericanAsian or Asian AmericanHispanic or LatinoAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther
Marital status

MarriedDivorceSingleWidowedSeparatedI choose not to answerOther
Upload picture ID/drivers license here

Cancelof
Check all those that apply*

NoneArthritis/GoutAsthmaBlood clotsCirculation problemsColitis/bowel diseaseCongestive heart disease (CHF)Coronary artery disease (CAD)COVID-19/Flu CurrentDiabetesEmphysema/COPDHeart attackHeartburn/GERDHigh blood pressureHIV/AIDSRenal failure or diseaseStomach ulcersStrokeThyroid diseaseTuberculosisUrinary tract infection (UTI)Other
Surgical History - check all that apply*

No surgical historyAbdominalAppendectomyBrainBreast biopsyBroken bones/fracturesCABG/Heart bypassCardiac stentColon removalC-sectionGall bladder removalHernia repairHysterectomyJoint replacementMastectomyTonsillectomyVasectomyOther
Are you currently pregnant, may be pregnant, or breast feeding?*

YesNo
Do you have a history of cancer and/or undergoing chemotherapy?*

YesNo
If yes to chemotherapy, have you received chemotherapy, or are you scheduled to start chemotherapy, within the past/next two (2) weeks?

YesNoN/A
Do you currently or in the past use nicotine?

Yes in the past I did, but no longer use nicotine of any typeYes I currently use nicotineNo I never used nicotine in the past and I currently do not use nicotineOther
Do you have any of these symptoms? Check all that apply.*

Fevers/chillsFatigueWeight loss or gain of 5 lbs or moreHave none of these symptomsOther
Do you have any of these listed symptoms regarding eyes/ears/nose/throat? Check all that apply.*

Vision changePain in eyesHearing problems or ear issuesSmell and nose problemsDizzinessSinus congestion/pressureSwelling/lumps in throatProblems with your throat or swallingI have none of these symptomsOther
Do you have any of these cardiovascular symptoms? check all that apply.*

Chest painPalpitationsEdema/swelling in legsI have none of these symptomsOther
Do you have any of these respiratory symptoms? Check all that apply.*

Abdominal painConstipationHeartburn/ingestionDifficulty swallowingNausea/vomitingFrequent urinationPainful urinationBlood in urine or stoolUrinary or stool incontinenceI have none of these symptomsOther
Do you have any of these musculoskeletal symptoms? check all that apply.*

Back or neck painJoint pain or swellingMuscle painI have none of these symptomsOther
Do you have any of these skin symptoms? check all that apply.*

RashSkin growthNew or changed molesPersistent itchI have none of these symptomsOther
Do you have any of these neurological symptoms? check all that apply.*

HeadachesChange in thinking or processingMemory lossTrouble speakingWeaknessLoss of coordinationNumbnessFalling or unsteady gateI have none of these symptomsOther
Do you have any of these endocrine symptoms? check all that apply.*

Excessive/increased thirstHeat/cold intoleranceToo hot or too coldI have none of these symptomsOther
Current weight*
Current height *
Do you have a health care advanced directive or guardian?*

YesNo
Emergency Contact Name

First NameLast Name
Emergency contact phone
Please enter a valid phone number.
May we contact your emergency contact in the case of emergency?

YesNo
Are you currently taking any over the counter medication, prescribed medications, or vitamins? If yes, state name and dosage amount. *
Do you have any known allergies to food or medication? If yes, state the allergy. *
Additional documents to upload (i.e., medical records or blood work you want us to review)

Cancelof
Acknowledgment, Authorization and Waiver
1. I authorize On the Move Mobile IV & Medical to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
2. I confirm that I read and understand where to find the patient rights, disclosures, and terms and conditions. And at any time I can ask for further clarification by emailing leadership@mobileivmedical.org
3. I understand that I can decline treatment at anytime without consequences.
4. I understand that consent to treatment is ongoing and I can withdraw at any time and that when consents are updated by this office I will have the opportunity to review and sign them again or every 12 months annually at minimum.
5. I acknowledge that all information I provided in this form is true and accurate.
I Agree to the above 5 bullet points of the acknowledgement, authorization and waiver agreements*

Yes
Office Policies and Forms
I understand I can review the patient rights, disclosures, and notice of privacy practices on mobileivmedical.org website at anytime. I understand I can also review these policies by clicking the below links before selecting I agree.
Patient name

First NameLast Name
Patient Signature*

Clear
Today's Date*

MonthDayYear
Date
Guardian name (when applicable)

First NameLast Name
Guardian Signature (when applicable)

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

On the Move Mobile IV and Medical

Acknowledgment, Authorization and Waiver

Office Policies and Forms