Patients filling out this form must have an appointment already scheduled. Please fill out this form at least 48 hours prior to your appointment. All fields must be filled out as completely as possible to ensure your chart is set up accurately.  Your form will be evaluated by a physician prior to your appointment time and your chart will be active upon arrival to your scheduled appointment. This ensures a better patient experience for you!

[Note: If you are unable to see this form, please scroll down all the way to the bottom of your screen and click on “Exit Mobile Mode”]

First and Last Name(required)

Email(required)

What is the Date and Time of your appointment?(required)

Phone Number(required)

Address(required)

City(required)

State(required)

ZIP(required)

Date of Birth(required)

Do you have health insurance?(required)

How did you hear about us?(required)

Which package have you purchased?(required)

Race(required) Caucasian

African American

Asian

Hispanic

Multi-racial

Other

Sex(required) Male Female

Marital Status(required) Single Married Divorced Widowed

Occupation(required)

Reason For Visit(required)

Allergies(required)

Past Medical History(required)

Do you have Fibromyalgia?(required) Yes No

Do you have Chronic Fatigue Syndrome? Yes No

One a scale of 1-10, how motivated are you. (10 being very motivated)

Are you taking any blood thinners?(required) Yes No

Are you pregnant or breast feeding?(required) Yes No

Past Surgical History(required)

Prescription Medications(required)

Non-prescription Supplements/Vitamins(required)

Do you smoke?(required) Yes No

Do you drink alcohol?(required) Yes No

Do you use illicit drugs?(required) Yes No

Do you exercise?(required) Yes No

Consent to Treatment and other Acknowledgements: By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments by Injections R Us Staff including injections, infusions, examinations, medications, anesthesia, medical services, and surgical or diagnostic procedures (including but not limited to the use of lab and radiographic studies) as ordered or approved by my attending physician(s), or any healthcare professional assigned to my care by my attending physician(s), and I acknowledge and consent to the following: During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures (“procedures”) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, I will ask my physician(s) to provide me with additional information. I also understand my physician may ask me to sign additional Informed Consent documents relating to specific procedures. Anytime an injection is given, there is potential for pain, bruising, or swelling at the injection site. These reactions are fairly mild and self-limited and usually resolve within 24-48 hours. Rare allergic reactions to the injection or infusion may occur. It is important that you inform the health care professional or proceed to the nearest emergency room if you experience severe side effects such as difficulty breathing, lips swelling, hives and chest pain. Physicians and healthcare professionals cannot guarantee any specific result(s) of any examination, treatment, procedure or medical care. I release the Injections R Us staff, its physicians and healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of Injections R Us or its employees.I understand that the healthcare professionals involved in my care will rely on my documented medical history, as well asother information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend procedures. I agree to provide accurate and thorough information regarding my medical history and any conditions or events which may impact medical decision-making. In return for services to be provided by Injections R Us, I agree to pay for services rendered by Injections R Us to me or for my benefit. I agree to pay in full for such services at the time the services are received. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and any questions I had have been answered to my satisfaction. I believe I have adequate information and knowledge upon which to base an informed consent to the proposed procedure (Injection/Infusion). I am aware of the potential risks involved as outlined above.(required)

Signature (First and Last Name)(required)

Dated (mm/dd/yy)(required)

Submit

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