New Patient History & Consent

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Primary Healthcare Provider's Name*

Not to be confused with In Home Infusion provider, if not applicable just enter "n/a"

Physician's Phone Number*

If not applicable you may enter n/a"

Do you have any allergies?*

If not applicable just put "n/a"

Weight*

Pre-Therapy Blood Pressure Reading

For hypertensive patients that have personal blood pressure monitors

Please list any other diagnoses you are aware of

You may enter "n/a" if not applicable

YesNo

What prescription medications and/or supplements are you presently taking?*

Enter "n/a" if not applicable

Are you pregnant or breastfeeding*

YesNoNot applicable

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform In Home Infusion of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate procedures.*

Full name of Signee*

First NameLast Name

Relationship if other than patient

Date of signature *

Date

Signature*

Full Name of Signee*

First NameLast Name

Relationship if other than patient

Date

Signature

I understand that these intravenous and intramuscular therapies contain specific formulas of nutrients (vitamins, minerals, and amino acids), compounded in an FDA-approved pharmacy and supplied by a third-party provider. Additionally, FDA-approved medicines may also be supplied by a third-party provider. While this procedure may be considered medically unnecessary, it has been recommended to you with the belief that it could be beneficial in your current circumstances and may likely improve both the condition for which you are being treated and your overall health.*

I acknowledge and accept that the procedure involves inserting a needle into a vein, placing a soft catheter, and administering the chosen therapy. This is performed by a healthcare practitioner operating within their state-regulated license and guidelines, under the supervision of a physician.*

I acknowledge and accept that the benefits of intravenous therapy include, but are not limited to, the following: All the specific benefits related to my intravenous or intramuscular therapy, optimized absorption of supplements and hydration as they bypass the gastrointestinal system, allowing for higher doses to be delivered directly to the cells through osmosis, reduced gastrointestinal discomfort associated with orally ingesting supplements, and increased safety since these intravenous supplements are water-soluble, meaning any excess is excreted by the kidneys.*

I acknowledge and accept that although uncommon, there are risks and side effects associated with receiving intravenous therapy, even when administered properly. While most side effects are extremely rare, some may be experienced more commonly, varying from person to person based on their current health and medical history. Potential side effects include, but are not limited to: discomfort, burning or stinging sensation, and/or pain at the injection site; a sense of swelling or bloating over the entire body; changes in the appearance of skin and tissue around the insertion site, such as bruising; inflammation of the vein used for injection (phlebitis); misplacement of the intravenous catheter during insertion (infiltration); bleeding at the insertion site; scarring or injury at the insertion site, including vein, nerve injury, and tissue necrosis; gastrointestinal upset such as nausea, vomiting, diarrhea, constipation, indigestion, and heartburn; metabolic disturbances; headache; allergic reactions including itching, hives, rash, swelling, difficulty breathing, wheezing, and anaphylaxis; muscle spasms, weakness, fatigue, dizziness; infection, chills, fever; cardiovascular disturbances such as rapid heart rate, palpitations, chest pain, flushed face, and vagal response; and in rare cases, cardiac arrest, air embolism, or death.*

I acknowledge and accept that it is my responsibility to promptly notify and seek immediate medical attention if any of the aforementioned side effects occur and are severe or troublesome, necessitating medical evaluation.*

To the best of my knowledge, I have thoroughly documented and informed my healthcare practitioner(s) in writing about any known allergies, current medications and supplements, all past and current medical conditions, diseases, and disorders, as well as any other relevant personal, health, social, and lifestyle information to minimize the risk of complications.*

I acknowledge and accept that certain medications or supplements, whether natural, over-the-counter, or prescribed, as well as known or unknown medical conditions, may increase my risk of the aforementioned side effects and risks. If receiving intravenous Benadryl, I should not drive, use machinery, or engage in activities that require alertness or clear vision for 4-6 hours after the medication is administered.*

I confirm that I do not have, and am aware of, contraindications for receiving the proposed therapy, including but not limited to Myasthenia Gravis, kidney (renal) failure, end-stage kidney (renal) disease, uncontrolled bleeding or blood clotting disorders (e.g., hemophilia), or heart disease (e.g., arrhythmias, atrial fibrillation, cardiomyopathy, congestive heart failure).*

I acknowledge and accept that unforeseeable complications may occur. I do not expect the healthcare practitioner(s) to anticipate or explain all risks and possible complications. I trust the healthcare practitioner(s) to exercise their judgment during the course of the therapy regarding my procedure. I understand the procedure, its risks and benefits, have had the opportunity to ask all my questions, and have the right to refuse or stop the infusion at any time.*

I acknowledge and accept full responsibility for any adverse effects that may arise from the proper administration of the proposed intravenous therapy. I waive any legal or equitable claims for redress of any grievances related to or resulting from the procedure, except in cases of negligent administration.*

I acknowledge and accept that the nature and purpose of the aforementioned therapy may be considered unproven by scientific testing and peer-reviewed publications. As a result, it may be deemed medically unnecessary or not currently indicated.*

I acknowledge and accept complete responsibility for informing all current and future healthcare provider(s) of my receiving the proposed intravenous therapy. I assume responsibility for discussing the appropriateness of my receiving the proposed intravenous therapy with my healthcare provider(s).*

I hereby acknowledge and accept that I understand that this procedure is not covered by my insurance. I agree to be personally and legally responsible for payment at the time of service for all services, including non- covered services.*

I further acknowledge and accept that in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.*

I understand my personal information will be kept private and protected in compliance with HIPAA.*

I agree to have personal non-identifiable factors and my infusion information used or released by In Home Infusion for research purposes. However, under no circumstance will any personal information be made available to the public, or disclosed by, In Home Infusion, with the exception of this Consent Form and nursing notes.*

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the intravenous and/or intramuscular therapy with its associated risks, known and unknown. I hereby give consent to an In Home Infusion registered nurse to perform the subsequent intravenous and/or intramuscular therapy with the above understood. I hereby release the Medical Doctor, the healthcare practitioner performing the intravenous and/or intramuscular therapy, and In Home Infusion Limited Liability Company, as well as any third-party suppliers from any and all liability.*

Name*

First NameLast Name

Date of signature*

Date

Assigned Licensed Nurse Name*

First NameLast Name

Dr. Andrew Epstein, DO (NPI #1902141930), has pre-approved the consent for an In Home Infusion contracted and licensed nurse to perform IV therapy after the patient has been cleared of contraindications.

Cancellation Policy

Please be advised that IV and IM therapy may still be canceled after pre-approval due to sudden contraindications such as hypertension. Other potential contraindications include unexpected allergic reactions to medications or substances used in the therapy, signs of infection at the injection site or systemic infections, severe dehydration that may complicate the therapy, acute cardiac issues or arrhythmias, and sudden onset of breathing difficulties or asthma attacks. These conditions can arise unexpectedly and may necessitate the cancellation of the therapy for patient safety. A cancellation fee of $100.00 may be applied to every therapy that is cancelled after nurse departure and signed consent to cover nurse expenses and doctoral fees. A nurse visit fee of $150.00 may be applied in unforseen scenarios of hypertension. We appreciate your understanding and cooperation.

New Patient History & Consent

Medical History

Intravenous and Intramuscular Therapy Informed Consent and Waiver of Liability

Please initial the following below as acknowledgement and acceptance of therapy standards and risks

Patient or Guardian please sign below