Veteran Owned and Operated

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Sheila L. Uridil, MSN, APRN, AGACNP-BC, ANP-BC
Joseph E. Uridil IV, MSN, APRN, AGACNP-BC
NeighborhoodHealthcareJ.S@gmail.com

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IV WELLNESS EXPERIENCE | HEALTH INTAKE & MEDICAL CLEARANCE

Personalized Wellness Infusion Therapy
Supervised by Sheila Uridil, ANP-BC, AGACNP-BC and/or Joseph Uridil, AGACNP-BC


YOUR WELLNESS GOALS

What are you hoping to achieve today?*
What are you hoping to achieve today?
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HEALTH HISTORY REVIEW

To ensure your treatment is both safe and personalized, please select any that apply:*
To ensure your treatment is both safe and personalized, please select any that apply:
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CURRENT MEDICATIONS / ALLERGIES

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CLIENT ACKNOWLEDGMENT

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To the fullest extent permitted by Arizona law:

I voluntarily elect to undergo IV therapy through Neighborhood Healthcare and knowingly assume all inherent and disclosed risks associated with treatment.

I release and hold harmless Neighborhood HealthcareSheila Uridil, ANP-BC, AGACNP-BCJoseph E. Uridil AGACNP-BC, employees, contractors, and agents from claims, damages, liabilities, or causes of action arising from:

  • Known or unknown complications inherent to IV therapy 
  • Allergic/sensitivity reactions not previously known or disclosed 
  • My failure to disclose relevant medical history 
  • My failure to follow instructions or seek timely follow-up care
  • Lack of desired treatment effect
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THE FOLLOWING SECTION IS TO BE FILLED OUT BY THE CLINICAL TEAM ONLY
PROVIDER WELLNESS ASSESSMENT

Vital Signs

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Clinical Evaluation

General Appearance*
General Appearance
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Hydration Status*
Hydration Status
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Venous Access Assessment*
Venous Access Assessment
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Medical Clearance

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PERSONALIZED INFUSION PLAN

Selected Formula / Additives*
Selected Formula / Additives
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Ascorbic Acid (Vitamin C) 200mg; Vitamin A (as palmitate) 3,300IU; Vitamin D3 (cholecalciferol) 200IU; Thiamine (Vitamin B1) 6mg; Riboflavin (Vitamin B2) 3.6mg; Pyridoxine HCl (Vitamin B6) 6mg; Niacinamide 40mg; Dexpanthenol (provitamin B5) 15mg; Vitamin E 10IU; Vitamin K1 150mcg; Folic Acid 600mcg; Biotin 60mcg; Vitamin B12 5mcg

Volume / Administration Rate*
Volume / Administration Rate
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To be signed by the healthcare provider only.
Sheila Uridil, ANP-BC, AGACNP-BC
Joseph Uridil, AGACNP-BC

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