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Hydrip Wellness Patient Intake Form

Please answer to the best of your knowledge so your treatment plan will be as effective as possible! Thank you for your time with Hydrip Wellness, we'll speak to you soon!

Name

Phone Number

Email

Gender

A
B

Date of Birth

MONTH
DAY
YEAR

Address

Is your shipping address the same as your home address above?

A
B

What brings you in?

What are you interested in? (check all that apply)

What is your main goal?

Goal weight (optional)

Have you ever taken a GLP-1 medication (such semaglutide or tirzepatide) before?

A
B

Medical History

Primary Care Doctor

Height

Current Weight

Are you on any medications?

A
B

Personal medical history: have you ever been treated for, or diagnosed with, any of the following? (check all that apply)

Have you had any major surgeries?

A
B

Have you previously been treated for cancer?

A
B

Any allergies? If so, please list them and your reaction

Untitled multiple choice field
A
B

Do you workout?

A
B

Do you drink alcohol?

A
B

Do you smoke?

A
B

Do you use recreational drugs?

A
B

Have you had bloodwork done in the past 24 months?

A
B

Family Medical History

Family medical history: has a blood relative had any of the following? (check all that apply)

Family medical history: none of the above

Texting permission

Patient Signature

Have you booked your consult call yet?

A
B

Today's Date

By signing below, I confirm that the information I have provided is true and complete to the best of my knowledge. I understand that the Hydrip Wellness care team, including our medical director, will review my intake before any treatment is approved or prescribed, and that submitting this form does not guarantee treatment.
SIGNATURE

If you need ANYTHING feel free to text, or call! phone: 480-480-3747

email: hello@hydrip.co the gram: @hydripwellness Thank you, talk soon!