IV Infusion Medical Intake | Renew Weight Loss Med Spa

Home
About Us
- Press
Our Services
Testimonials
Blog
RENEW Health Products
Contact Us

Home
About Us
- Press
Our Services
Testimonials
Blog
RENEW Health Products
Contact Us

Call /Text (413) 438-5737

IV Infusion Medical Intake

Name:

Phone:

Email:

Current Health Concerns (Check all that apply)

Fatigue or Low Energy

Stress

Brain Fog

Weight Gain

Slow Metabolism

Headaches/Migraines

Recent Illness/Surgery

Asthma/Allergies

Cold/Flu Symptons

Dull or Dry Skin

Malabsorption Issues

Other

Are you pregnant or breastfeeding?

Yes

No

What type of infusion are you interested in?

Boost energy & wellness

Strengthen immunity

Support weight loss

Improve skin health & anti-aging

Detox & remove toxins

Recover from illness/surgery/hangover

Date of Last Lab Test

Have you been told you have an electrolyte imbalance?

High magnesium (Hypermagnesemia)

High calcium (Hypercalcemia)

Low potassium (Hypokalemia)

High iron (Hemochromatosis)

Other

Do you have allergies to any of the following?

Latex

Shellfish

Iodine

Cobalt

Food Preservatives

Gluten

Milk

Other Medications

Do you take prescription medications?

Yes

No

If you do, please list them below

Do you take over-the-counter drugs, vitamins, or supplements?

Yes

No

If so please list below

Do you take any of the following?

Digoxin (Lanoxin)

Diuretics (water pills)

Steroids (e.g., Prednisone)

None of the above

Do you smoke?

Yes

No

If yes, about how much per week?

Do you have any of the following conditions? (Check all that apply)

High/low blood pressure

Heart problems

Stroke

Kidney disease/stones

Liver disease

Diabetes

Asthma

G6PD Deficiency

Sickle Cell Anemia

Optic Nerve Atrophy

Parathyroid issues

Cancer

Anxiety/Panic Attacks

Do you drink alcohol?

Yes

No

If yes, about how much per week?

Do you use recreational drugs?

Yes

No

If yes, which ones?

Have you had any past surgeries?

Yes

No

If yes, list procedures and dates

Additional Notes for the Provider

Thank you for completing our form.

Oops, there was an error sending your message.
Please try again later.

CONTACT INFORMATION

renewweightlossLLC@gmail.com

235 Chestnut st, Springfield, MA

BUSINESS HOURS

Saturday - 10AM to 6PM

Monday - 9AM TO 3:30PM

Additional evening weekday hours can be added if necessary.

© 2025

All Rights Reserved | Renew Weight Loss Med Spa

Privacy Policy | Contact Us

Share by: