INFUZE PATIENT HISTORY & CONSENT FORM

PATIENT HISTORY QUESTIONNAIRE & CONSENT FORM
INFORMED CONSENT FORM
This document is intended to serve as confirmation of informed consent for Intramuscular injections and/or Intravenous therapy treatments provided by INFUZE Wellness Center.

I, as a client 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 to give my informed consent. Your treatment is elective by choice and by no means constitutes any substitute for medical evaluation and treatment for any illness.
I understand that:

1) The procedure involves inserting a sterile needle into a muscle or a vein and infusing the desired item from the INFUZE menu directly into your body.

2) An alternative to intravenous therapy is oral supplementation  

3) Risks of intravenous therapy include but not limited to:  

a) Occasionally to commonly
i) Discomfort, bruising and pain at the site of injection

b) Rarely
i) Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury

c) Extremely Rarely
i) Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death

d) Benefits of intravenous therapy and injectable supplements include:
i) The ability to provide prompt fluid replacement and hydration
ii) The total amount of the infusion is available to the tissues.
iii) Nutrients are forced into cells by means of a high concentration gradient.
iv) Higher doses of nutrients can be given without causing intestinal irritation, during bouts of nausea or vomiting, easy to monitor delivery, and provide immediate results.

Your signature below means that:

1. You have read and understand the information provided in this form

2. The procedure has been adequately explained and all your questions have been addressed

3. You have received all the information and explanation you desire concerning the procedure

4. You authorize and consent to the performance of the procedure as agreed upon with INFUZE.

5. You are of sound mind and able to make a rational decision

By signing this consent, I acknowledge that the risks, benefits and alternatives have been discussed and explained to me. The procedure has been adequately explained and all of my questions have been addressed. I have been advised that this procedure may be beneficial in my condition. I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND ALL MY QUESTIONS HAVE BEEN ANSWERED.
General Information:

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Patient Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Age*
Gender*

MaleFemalePrefer not to say
Emergency Contact Information

____________________________________________________________________________________________________
Emergency Contact Name*

First Name Last Name
Emergency Contact's Phone Number*
Please enter a valid phone number.
Emergency Contact's Relationship *
Medical History

____________________________________________________________________________________________________
Have you had a history with Diabetes?*
Have you had a history with Heart Disease/ Heart Attack?*
Have you had a history with Congestive Heart Failure?*
Have you had a history with Palpitations or Tachycardia?*
Have you had a history with Kidney Disease?*
Have you had a history with Dialysis?*
Are you currently Pregnant or Breastfeeding?*
Have you had a history with Panic attacks or Anxiety?*
Current Medications & Supplements
Allergies to medications
Social History

____________________________________________________________________________________________________
Do you use tobacco?*
Do you use alcohol?*
Do you use recreational drugs?*
Patient Authentication

____________________________________________________________________________________________________
I confirm that all information provided above is true and accurate to the best of my knowledge.
Where did you hear about us?
Signature

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PATIENT HISTORY QUESTIONNAIRE & CONSENT FORM

INFORMED CONSENT FORM

General Information:

Emergency Contact Information

Medical History

Social History

Patient Authentication