Client Intake Full Name(Required) First Last Address(Required) Street Address Address Line 2 City ZIP Code Phone(Required)Email(Required) Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920In case of emergency, name and phone number of person you want us to contact(Required)List all medications you are currently taking. Enter N/A for none.(Required)List all known allergies. Enter 'N/A' if you are unaware.(Required)Have you ever had IV Hydration before?(Required)NoYesAny problems that occur when you are injected?(Required)NoYesWhat have you experienced? (None of the Above)(Required) Fatique Low Depressed Mood Pernicious Anemia Weight Issues Irritability/Moodiness Pregnant/Trying to Get Pregnant Heart Disease Diabetes Memory Loss/Alzheimer’s Sleep Disorder Osteoporosis Tendonitis Asthma Immunosuppression Thyroid disorder IBS/Inflammatory Bowels Numbness/ Tingling of Body High Blood Pressure Sickle Cell Anemia Weigh Loss Surgery None of the Above Select AllAny current health issues? N/A for none.(Required)Consent(Required) I agree(Required)I consent to all nutrient injections rendered by the the licensed professional medical staff associated with Moon Valley Med Spa. I understand that there are risk to vitamin nutrient injections including but not limited to pain, bruising, inflammation, injury, infection, allergic reactions, headaches, dry mouth, difficulty sleeping, diarrhea, blurred vision, unpleasant taste, increase urination, cramps, and metabolic disturbances. I do not expect the persons employed or associated with Moon Valley Med Spa to anticipate and or explain all risk and possible complications. I hereby release the professional medical staff at Moon Valley Med Spa from all liabilities regarding my treatment with vitamin/nutrient injections. I understand that nutrient injections may not be approved by the United States Food and Drug Administration for the treatment of my medical condition.