MO' HYDRATIONBy NurseInjectorMo
All FormsStep 1 · Before Your Visit

Medical Intake & Screening

Complete this form before your appointment. Your responses help us determine the most appropriate hydration option for you and screen for any contraindications. This form includes the Virginia-mandated Good Faith Exam.

Client Information
Today's Visit
Health Screening

Do you currently have or have a history of any of the following?

Virginia Mandated
Good Faith Exam — Client Medical Review

The following medical review is required by the Commonwealth of Virginia prior to elective IV hydration and infusion therapy. Your provider will complete the medical clearance portion of this exam during your visit.

1. Do you have any current medical conditions?

2. Are you currently taking prescription medications, OTC medications, vitamins, or supplements?

3. Do you have any medication, food, latex, or other allergies?

4. Do you have a history of any of the following?

5. Are you currently pregnant, breastfeeding, or possibly pregnant?

6. Have you had a recent hospitalization, surgery, serious illness, or emergency-room visit?

7. Are you currently experiencing chest pain, shortness of breath, severe dizziness/fainting, severe vomiting/diarrhea, confusion, significant swelling, or another acute medical concern?

8. Have you previously received IV hydration or vitamin therapy?

Previous reaction or complication?

Provider Documentation / Medical Clearance: The medical clearance portion of this Good Faith Exam — including clearance status, approved treatment, provider name/credentials, date/time, and signature — is completed by your provider during your visit and is not part of this client form.

Medications & Allergies

Replenish. Recover. Refresh. — By NurseInjectorMo

MO' Hydration provides elective IV hydration and wellness services. These services are not intended to diagnose, treat, cure, or prevent any disease and do not replace emergency or primary medical care. All treatment is based on an individualized clinical assessment. Individual responses vary and no specific result or health benefit is guaranteed. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.