Methylene Blue Therapy Patient Identity Verification Form

Methylene blue therapy is an emerging experimental treatment that shows promise for mitochondrial function enhancement and cognitive support. Healthcare providers offering this innovative therapy need a robust patient verification and screening system to ensure safety, compliance, and informed consent.

This Methylene Blue Therapy Patient Identity Verification Form template provides a complete intake and screening solution designed specifically for telehealth and alternative medicine practitioners. The form combines identity verification, comprehensive contraindications screening, mitochondrial function assessment, and detailed treatment acknowledgment in a single streamlined workflow.

The template helps healthcare providers verify patient identity through photo ID upload, screen for potentially dangerous drug interactions and contraindications (including G6PD deficiency, SSRI use, and other critical factors), assess baseline mitochondrial function symptoms, establish appropriate dosing protocols, and obtain informed consent for experimental treatment.

Built with Paperform's conditional logic, this form adapts based on patient responses—automatically flagging contraindications and adjusting follow-up questions based on medical history. Healthcare providers can collect secure photo identification, insurance information, and medical records while maintaining HIPAA-aware data handling practices.

The form integrates seamlessly with telehealth workflows using Stepper to automate patient onboarding, trigger provider reviews for flagged contraindications, schedule follow-up consultations, and maintain organized patient records across your practice management tools. Whether you're a functional medicine practitioner, integrative health clinic, or research-focused provider, this template streamlines the complex process of safely onboarding patients for experimental methylene blue therapy.