Hydration Therapy Service Forms

Serving Kansas City


In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.

    Please check all that apply
  • Please List
    Check all that apply.
  • What oral prescription medications are you presently taking? (It is required you list all of them) If you are not taking any medications type 'None'.
  • (It is required you list all of them) If you are not taking any supplements type 'None'.
  • For Our Female Patients

    I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. The treatments I receive here are voluntary. I understand there is a risk, including but not limited to, allergic reaction, skin irritation, nausea, vomiting, gastrointestinal upset, and flushing. I release Recovery Hydration Therapy, INC and my provider from liability and assume full responsibility.
  • This field is for validation purposes and should be left unchanged.

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