**Schedule Your Recovery & Performance Mobile IV Therapy**

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Drip

County

First Name *

Last Name *

Date of birth *

Phone *

Email *

Medical Screening

Please select ALL of the following that apply to you: *

I have been diagnosed with or told I have congestive heart failure (CHF)

I have been diagnosed with or told I have hemophilia

I have been diagnosed with or told I have kidney/renal failure or chronic kidney disease (CKD)

I am on dialysis

I have been diagnosed with or told I have pulmonary arterial hypertension (PAH)

I have a history of uncontrolled bleeding

I have impairment preventing myself from making medical decisions and/or consenting to my treatment

I currently have fluid build up in my feet, legs, or abdomen

I take medicine(s) for fluid retention (i.e. diuretic)

None of these

Consent

I agree to terms, privacy policy and Cancellation Policy

I acknowledge that My Drip Nurse does not directly provide healthcare services but facilitates scheduling appointments for the required treatments to be administered by a licensed medical provider (the "Medical Provider") authorized in the state where the services are rendered. I understand that My Drip Nurse will relay my prior medical history to the Medical Provider, who will assess the suitability of the treatment(s) and carry out or supervise the procedure(s) according to their professional medical judgment. I affirm that all medical, medication, and personal history information provided, including any previously disclosed details, is accurate and truthful. I recognize my obligation to keep My Drip Nurse and the Medical Provider informed of any changes in my health status and to update my medical history as needed. Maintaining an up-to-date medical history is crucial for the proper implementation of the treatment plan.

Consent Signature *

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