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.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

    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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