IV THERAPY CLIENT CONSENT FORM PDF Consent Form Name * First Name Last Name Date of Birth MM DD YYYY Age Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Phone * (###) ### #### How did you find us? Medical Questionnaire For Nutrient IV Therapy In order for us to serve you better. Please answer the following: Select Yes or No: If yes to any question, please explain. Have you now or had in the past? Congestive Heart Failure? * Yes No Severe Renal Impairment? * Yes No Heart Attack / Stroke? * Yes No Condition of Sodium Retention or Electrolyte Imbalance? * Yes No Edema Water Retention? * Yes No High / Low Blood Pressure? * Yes No Severe Frequent Headaches? * Yes No Fainting / Seizures / Epilepsy? * Yes No Diabetes / Low Blood Sugar? * Yes No Any liver conditions? (e.g. Liver Cirrhosis, Liver Disease) * Yes No Any allergies? * Yes No If yes, please list here. Do you have Sulfa Allergies? * Yes No Do you have or have had asthma? * Yes No What is your medical history? Please list. Females Only: Are You Pregnant? Yes No If yes to any question, please explain. Have you now or had in the past? Terms, Conditions & Consent for IV Hydration Therapy Our hydration therapy is specifically designed to counteract symptoms of dehydration, fatigue, and the residual effects of nutrients and H2O depletion. We offer no diagnostic testing, make no medical diagnoses, and reserve the right to refuse treatment to any patients we deem are intoxicated unstable, or whose symptoms are not consistent with the above. The vast majority of our clients receiving our therapy feel greatly improved; however, every individual is different and there is no guarantee that you will feel better after an infusion; nor does your improvement of symptoms exclude other coexisting potential medical conditions. This document is designed to serve as confirmation of informed consent for IV therapy as suggested by the qualified staff present at the current location. - I have informed the staff of any known allergies to drugs or other substances, or of any past reactions to anesthetics. - I have informed the staff of all current medications and supplements I am taking. - I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and give my concerns. I understand that the procedure involves inserting a needle into a vein and injecting the selected solution. * I agree I understand that risks of intravenous therapy include, but are not limited to: discomfort, bruising, and pain at the site of injection. * I agree I understand that other rare but possible side effects include but are not limited to: inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. * I agree I understand that nutrients are forced into the cells by means of a high concentration ingredient. * I agree I understand the information provided on this form and agree to the foregoing. * I agree I have received all the information and explanation I desire concerning the procedure. * I agree I authorize and consent to the performance of the procedures(s). * I agree Signature * I agree to conduct this transaction by electronic means and consent to the use of electronic signatures to accord full legal effect. Today's Date * MM DD YYYY Thank you for filling out the IV Therapy Consent Form! PDF Consent form
