Peak Performance HydrationNEW-PATIENT INTAKE

42201 N 41st Dr, Suite 122
Phoenix, AZ 85086
(623) 282-1201
peakperformancehydration.com

Before your first visit

New-patient intake.

Bring this completed, or fill it in when you arrive. It helps our physician tailor and clear your drip.

Your details

Full name

Date of birth

Phone

Home address

Emergency contact name

Emergency contact phone

Health snapshot

Current medications & supplements

Known allergies (medications, foods, latex)

Medical conditions (heart, kidney, thyroid, diabetes, pregnancy, etc.)

What are you hoping to get out of your visit today?

Consent to contact

Would you like appointment reminders and wellness updates? [ ] Yes, text me [ ] Yes, email me [ ] No thanks

Signature

Date

Note: This intake collects general wellness information only. Detailed clinical records are kept securely in our HIPAA-compliant clinical system.

Peak Performance Hydration · Veteran-owned · Medically supervised by a Board Certified Emergency Physician.
Questions? Call (623) 282-1201 or visit peakperformancehydration.com.