What to include in an IV therapy intake form (plus a handy template)

    a patient filling out an IV therapy intake form

    Intake forms are like your patients’ IDs. 

    They help you understand a patient’s health information so you’re fully informed about any underlying medical conditions before they receive IV therapy.

    When you have this essential information about your patients, you can perform safe, effective, and personalized infusion therapy treatments, avoid administrative errors, and maintain the highest level of patient safety and data privacy.

    A comprehensive intake form helps to assess a patient’s suitability for IV therapy and identify any potential risks or contraindications that may prevent them from receiving it. But what do you actually include in the IV therapy intake form?

    Below, we’ve mapped out exactly what to include in your intake form and included a handy template that you can steal for your own practice.

    What does an IV therapy intake form need to include?

    Your IV therapy intake form should collect detailed patient information about various aspects of the patient’s general health and lifestyle.

    This way, your practitioners can make an informed decision about the suitability of the client for the treatment. At the same time, you can provide safe and efficient treatment and smooth practice operations.

    Below, we break down the key components of a robust IV therapy intake form.

    Patient information and background

    This should be the first section of the IV therapy intake process.

    Accurate and comprehensive patient data helps build a clear patient profile, allowing you to provide personalized care and maintain robust client records.

    This includes:

    • Full name: To ensure the records match the patient
    • Date of birth: The patient’s age helps assess eligibility for certain treatments, understand age-specific health risks, and tailor therapy accordingly
    • Gender: It may help to understand specific health requirements 
    • Contact information: Accurate contact information (phone number, email address, and home address) allows you to send appointment reminders and follow-up instructions, and get in touch with them in case of any urgent issues.
    • Emergency contact: It’s crucial to have a record of this in case the patient experiences an adverse reaction or any medical emergency during or after the IV therapy session.

    Medical history

    Patients’ medical histories allow you to assess their overall health and determine whether they’re suitable candidates for IV therapy.

    This information helps you identify potential risks, contraindications, and any precautions you should take. The medical history section should include:

    • Current medications: You need to know all prescription medications, including dosages, to prevent adverse drug interactions and contraindications with the IV therapy treatment.
    • Allergies: Identifying any allergies, particularly to medications or ingredients used in IV therapy, is essential to avoid allergic reactions, which can be severe and life-threatening.
    • Past medical history: It’s critical to know about any chronic diseases the patient may have, like diabetes and hypertension, plus previous surgeries and hospitalizations gives context for their current health status and potential complications that may arise during IV therapy. Note: It’s also crucial to ask patients if they are pregnant, as it can impact the safety of the therapy.
    • Current symptoms or complaints: Recording current symptoms helps you diagnose underlying conditions that may affect the IV therapy process and modify the treatment plan if needed.
    • Recent illnesses or infections: They can impact the patient’s immune system and overall suitability for IV therapy. You need it to assess the risk of complications and determine the best timing for therapy.

    Speaking of patient intake, patient portals are extremely useful for collecting patient data, and they’re also a method favoured by clients. 

    78% of patients prefer using a secure online method to access their medical histories and share information with their doctor, while 59% of Gen Y patients say they would change doctors for one who offers better online access.

    Lifestyle and habits

    Patients’ lifestyles and habits can significantly impact their health, response to treatment, and overall well-being. Understanding them helps you provide holistic care and tailor the IV therapy to meet their needs.

    This means:

    • Smoking, alcohol, and drug use: These habits can influence the patient’s overall health, liver function, immune system, and response to IV therapy. For example, patients who smoke require higher doses of certain vitamins and antioxidants, as smoking depletes levels of vitamin C and other essential nutrients.
    • Dietary habits: A patient’s diet can affect their nutritional status, hydration levels, and response to IV nutrients. Make sure you collect information about daily dietary intake and eating patterns, any specific dietary restrictions or preferences (e.g., vegetarian, vegan, gluten-free), and the use of vitamins, minerals, or other supplements.
    • Exercise routine: Regular physical activity impacts cardiovascular health, muscle function, and overall energy levels. Knowing their routine tells you a lot about their fitness level and helps you tailor the IV therapy to support their recovery.

    💡 Did you know?: A study on the impact of IV therapy on cancer patients found that IV vitamin C may improve the quality of life (QOL).

    IV Therapy history

    Another important detail you want to know is the patient’s intravenous therapy history. Ask about their previous experience and take note of any side effects or adverse reactions so you can take them into account for their future treatment.

    There are two important components to this:

    • Previous IV therapy: Ask about the type of treatments they received (e.g., hydration, vitamin infusion, detox), frequency, and any adverse reactions they had, such as allergic reactions, nausea or dizziness). This helps you avoid repeating ineffective treatments and prevents complications from known reactions.
    • Current or recent IV therapy: In addition to past treatments, it’s crucial to know if the patient has had any recent or current therapies. You need this information to learn the effects of the therapies and plan the next ones to avoid overlapping or conflicting treatments.

    Consent and acknowledgment

    The consent and acknowledgment section is a critical component of the IV therapy intake form.

    It confirms that patients have a complete understanding of the treatment they will undergo, are aware of the potential risks and benefits, and acknowledge their informed consent to proceed.

    This section is critical for your practice to maintain ethical standards, protect patient safety, and ensure legal compliance. It also helps to protect your business in light of any complaints, so you can evidence that the client had consented to the treatment.

    Note: Some practices provide a separate consent form instead of a section in the intake form. You decide what works best for your practice and patients.

    Regardless of whether you choose to add this section to the intake form or as a separate consent form, it should contain these essential components:

    • Explanation of IV therapy: Provide a full description of the therapy, what it involves, potential risks, benefits, and alternatives so that the patients are fully informed and can make a decision.
    • Patient consent signature: It legally documents that the patient has read, understood, and agreed to the information about the IV therapy.
    • Date of consent: It’s crucial for maintaining accurate medical records and provides a timestamp when the patient was informed and in agreement. 

    💡 Pro tip: The Consent and Acknowledgment section should be written so that the patient, as someone with no medical knowledge, can understand it.

    Insurance information

    For patients who have insurance, this section is crucial to ensure that the cost of the therapy can be covered or reimbursed by the insurance provider.

    Collecting insurance information helps your practice manage billing, verify coverage and reduce out-of-pocket expenses for the patient.

    These details should be contained in this section:

    • Insurance provider: It’s necessary to verify coverage, understand the specific terms of the patient’s policy, and determine the extent of coverage for IV therapy.
    • Policy number: The unique number related to the patient’s insurance plan allows you to process claims and verify the benefits.
    • Group number: This number indicates the specific plan or employer group under which the patient is insured. It helps you identify the precise coverage details.
    • Insured’s name (if different from patient): Sometimes, the patient is covered under another person’s insurance policy (e.g., a spouse or parent).

    🧠 Pro tip: Providing digital intake forms not only makes the job easier for you, but your patients also love it, too. Research shows that 81% of patients prefer to fill out online intake forms from anywhere and on any device in contrast to paper forms in the waiting room.

    IV therapy intake form template to use

    IV therapy intake form template

    Disclaimer: The Consent and Acknowledgment section included in this template serves just as an example. You should always consult legal counsel to help you create one in accordance with your practice needs.

    Facilitate intake forms seamlessly with Pabau

    Intake forms are key to providing safe, effective, and personalized IV therapy treatments.

    They’re an essential tool to assess patients’ suitability for IV therapy, identify potential risks, document their consent, and tailor the infusion therapy to their unique needs.

    Pabau is an all-in-one practice management that takes a load off your plate in terms of managing digital intake forms and creating a smooth and frictionless intake process.

    It’ll help you with:

    • Flagging up allergies and contraindications 
    • Automatically sending intake forms and questionnaires to the client
    • Automatically sending pre-care and post-care to the client
    • Pulling data from forms directly into the client card
    • Managing your client records from anywhere
    • Marketing features to drive sales

    Take your intake forms and patient care to the next level and experience the difference Pabau can make for your clinic. Book a demo and see for yourself! ✨

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