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HALO MOBILE IV Hydration & Wellness

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Initial Intake Form

Please fill out this initial intake form prior to your appointment. At the time of your visit your RN will go into further detail regarding your health history.

First Name

Last Name

Email

Date of Birth

Are you currently being treated by a Physician for any medical condition? *

No

Yes

Are you currently taking any prescribed or over the counter medications? *

No

Yes

If you answered yes to any question, please elaborate

I confirm to the best of my knowledge I do not have G6PD

I confirm to the best of my knowledge I do not have any Sulfa drug allergies.

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

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