Thank you for your order!

Patient Name*

Patient phone #*

You are consenting to receive text messages or phone calls regarding your appointment.

Phone

Patient Email*

Consent and Acknowledgement to Contact*

You consent and acknowledge that you may be contacted regarding your appointment and/or services related to your appointment.

This can be done either by phone, email, text (including Whatsapp)

I consent and acknowledge the above.

Appointment Details:

Service Address:*

Please only put your street address

Example:

1235 Anywhere Ln.

Houston, TX 77071

Service ZIP Code*

Please confirm your Zip Code

Requested Date*

Time Slot Requested*

We can not always guarantee exact requested time slots but will do all we can to accommodate.

Select or enter value

Notes or comments for our staff.

Examples:

Gate codes for entry
Pets
Special care instructions

Medical Screening & Consent:

Are you currently pregnant?*

Yes

No

N/A

If pregnant, which trimester?

1st Trimester

2nd Trimester

3rd Trimerster

Any allergies?

Please list all known allergies.

Have you received IV in the past ? How long ago?

Please review the below prior to submitting.*

Acknowledgement and Liability Release :

By submitting this form and proceeding with your appointment you acknowledge and agree to the following:

In the event of a medical emergency, dial 911 immediately.

By proceeding with your appointment you acknowledge that this service is NOT a substitute for medical care, does not constitute a medical visit or evaluation and should not be used instead of calling your doctor or 911 in the event of a medical emergency.

The RN (nurse), Medic (paramedic), or other licensed individuals who will perform the service(s) are independently contracted and you will not hold them, Myhealthsight LLC, Gold Diagnostics Corp and its managers or affiliates, liable for any damages or loss(es) due to the services performed or not performed through our encounter.

By submitting and proceeding with your appointment you waive all rights for legal action or compensation from Myhealthsight LLC, Gold Diagnostics Corp and/or its affiliates.

We reserve the right to refuse service.

Some side effects from IV Therapy may include (not limited to)

Infection at the injection site or rashes, vein inflammation and bruising, swelling, muscle pain, blood clots or air embolism.

I consent and acknowledge the above.