FIRST NAME:
LAST NAME:
NICKNAME:
BIOLOGICAL SEX: IDENTIFY AS (If different from above):
ADDRESS:
CITY:
STATE:
ZIP:
CONTACT NUMBER:
DRIVERS LICENSE NUMBER (COPY REQUIRED ON CHECKIN)
EMAIL:
OCCUPATION:
HEIGHT:
CURRENT WEIGHT:
GOAL WEIGHT:
BP If Known
BIRTH DATE:
AGE:
EMERGENCY CONTACT:
CONTACT:
RELATIONSHIP:
MARITAL STATUS:    
PRIMARY PHYSICIAN:
DATE OF LAST VISIT:
LIST ANY MAJOR HOSPITALIZATIONS, OPERATIONS OR ILLNESS:
Tobacco Use:  
Drink Alcohol:  
Please list current symptoms & concerns prompting your visit
Symptom/Concern Date Of Onset Frequency Severity
Personal & Family History
Child Siblings Father Mother Self
ABNORMAL BLOOD PRESSURE
ARTHRITIS OR JOINT PROBLEMS
ASTHMA BRONCHITIS
AUTOIMMUNE DISEASE
BLOOD DISORDERS/ANEMIA
CANCER/TUMORS/CYSTS
COLITIS
CROHN'S DISEASE
DEPRESSION/MENTAL ILLNESS
DIABETES
ECZEMA/PSORIASIS
ENDOCRINE DISORDER
EPILEPSY
EXCESSIVE BLEEDING
GALLSTONES
HEART DISEASE
HERPES/COLO SORES
HIGH CHOLESTEROL/LIPIDS
HIV
HEPATITIS
HPV/HUMAN PAPILLOMAVIRUS
JAUNDICE/LIVER DISEASE
KELOIO SCARRING
KIDNEY INFECTIONS/STONES
EMPHYSEMA
MELANOMA/SKIN CANCER
PARASITES
PHLEBITIS/VARICOSE VEINS
PNEUMONIA
REOCCURRING INFECTIONS
RHEUMATIC FEVER
RHEUMATOID ARTHRITIS
THYROID DISEASE
TUBERCULOSIS
SEIZURES
STROKE
ULCERS
List current Rx Medicines & Used in the past 6 Months
Any Medication Allergies: 
Check all symptoms you have experienced in the last 6 months
FEMALE HORMONE HISTORY (N/A )
DATE OF YOUR LAST PERIOD: ARE YOUR MENSTRUAL CYCLES: 
ARE YOU CURRENTLY PREGNANT: NUMBER OF TOTAL PREGNANCIES:
LIVING:MISCARRIAGES
LAST DATE OF PAPS SMEAR:DATE OF LAST MAMMOGRAM:
HAVE YOU EVER USED ORAL CONTRACEPTIVES: BEGAN AT WHAT AGE:
EXPlAIN ANY PROBLEMS WHILE TAKING CONTRACEPTIVES:AGE STOPPED:
HAVE YOU HAD BREAST CANCER: WHEN:
HAVE YOU HAD OVARIAN CANCER: WHEN:
HAVE YOU HAD FIBROCYSTIC BREASTS:HAVE YOU HAD UTERINE FIBROIDS:
HAVE YOU HAD A HYSTERECTOMY: OVARIES REMOVED:
TUBIL LIGATION:
WHAT WAS THE REASON FOR YOUR HYSTERECTOMY:
WHAT WAS THE DATE OF YOUR SURGERY:
SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY
IRREGULAR PERIODSSWOLLEN TENDER BREASTSFACE IS WRINKLED & SLACK
LIGHT MENSTRUAL FLOWSWOLLEN BELLYLOSS OF MUSCLE TONE
VAGINAL DRYNESSIRRITABLE & AGGRESSIVE BEHAVIORINCREASED BELLY FAT
CRAMPSHEAVY PERIODSFATIGUED, FEELING EXHAUSTED
PAINFUL INTERCOURSEPAINFUL PERIODSREDUCED LIBIDO
HOT FLASHESLOSS OF SELF CONTROLMEMORY LAPSES/MENTAL FOG
HAIR LOSS ON TOP OF HEADRESTLESS, LIGHT SLEEPWEIGHT GAIN -WAIST, HIPS, THIGHS
DEPRESSEDANXIOUS
SCORE EACH FROM 0 -10, WITH 10 BEING HIGHEST:
CURRENT LEVEL OF BACK PAINSTRESS LEVEL PAST 30 DAYSENERGY LEVEL IN MORNING
CURRENT LEVEL OF JOINT PAINSTRESS LEVEL PAST 6 MONTHSENERGY LEVEL IN LATE AFTERNOON

This agreement between ("Patient'') and Revive IV Hydration lounge (Rll establishes guidelines and conditions for the use of IV Vitamin and Hydration Therapy. RL and patient agree that these guidelines and conditions are an essential factor In maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore. these agents are prescribed with caution. The patient agrees and accepts to the following conditions:

  1. I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In accordance with applicable state and Federal law.
  2. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
  3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
  4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effect related to my treatment to Revive IV Hydration Lounge and discontinue use until advised to resume usage by my health care
  5. provider. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy. ·
  6. I understand that representatives of Revive IV Hydration Lounge and/or Licensed Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of my treatment.
  7. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by Revive IV Hydration Lounge or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.
  8. I agree that the Revive IV hydration Lounge/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Revive IV Hydration Lounge will be in conjunction with the care provided by my current PCP.
  9. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.
  10. I have read and agree to the terms of this the Therapy Management Agreement.
  11. I consent to text message appointment reminders. (Data rates may apply)

This agreement between ("Patient") and Revive IV Hydration lounge establishes guidelines and conditions for the use of hormone replacement therapy ("HRT") involving DEA "controlled" or "scheduled" medications. PP and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution. The patient agrees and accepts to the following conditions:

  1. I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, and the results of lab work and a physical examination. The medications are to be used exclusively for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and Federal law.
  2. I understand and agree that no medical treatment or medication provided to me by
  3. Revive will be used for the purposes of bodybuilding, performance enhancement or physical appearance.
  4. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
  5. I will not attempt to obtain HRT medications from any other health care practitioner without disclosing my current medical usage of HRT or other medications. I understand that it may be against the law to do so.
  6. I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side effect related to the use of my HRT to Revive Vero LLC and discontinue use until advised to resume usage by Progressive Health Institute. I voluntarily assume any and all possible risks which may be associated with HRT.
  7. I understand that representatives of Revive Vero LLC and/or licensed Physicians Assistant are available for questions and/or concerning during normal business hours throughout the course of my treatment.
  8. I agree that the HRT medications furnished by Revive Vero LLC are for my personal use only and for no other purpose. I will not share, sell. or trade my medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
  9. I will be able to purchase the medications from the pharmacy designated by Revive Vero LLC and the pharmacy will send medication directly to me. I understand I have the right to purchase my medications from any
  10. pharmacy of my choice. If I chose to obtain medications from a pharmacy of my own choice, I must notify Revive Vero LLC in writing of my intention to do so and include the name of the pharmacy in my request.
  11. I agree and understand that federal regulations prohibit the return of prescribed medications.
  12. I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Revive Vero LLC or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.
  13. I agree that the Revive Vero LLC patient/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Revive Vero LLC will be in conjunction with the care provided by my current PCP.
  14. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
  15. I understand that Revive Vero LLC only treats patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current health history through either patient's personal physician or a Progressive Health Institute - affiliated physician. Agreeing to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.
  • I consent to text message appointment reminders. (Data rates may apply)

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