Intake & Consent Form

Intake & Consent Form
Date

Month Day Year
Date
Temperature
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Emergency Contact
Emergency Contact Number
Please enter a valid phone number.
Referral Name/How did you hear about us
Reason for IV hydration/Vitamin injection
Allergies *
Gender
Current Medications *
Medical Conditions *
Have you ever had a nutrient IV infusion? Yes or No
(What/When)
Problems with prior infusions including reactions, allergies, or access issues?
What is your treatment goal? (ex: increase energy, general wellness)
Do you have any of the following conditions?
Do you have any of the following conditions? *

End Stage Renal Disease Cerebral Hemorrhage Hyperparathyroidism G6PD Deficiency Myasthenia Gravis Hypermagnesium Kidney/Renal Disease Hemolytic Anemia Myxedema Current UTI Cardiac Arrhythmia None of the above
Have you ever been told you need to start dialysis or are you currently on dialysis?

Yes No
Are you taking or have you been told you need to take Digoxin?

Yes No
Have you been told you have a decreased GFR or kidney problem?
Have you been told you have a decreased GFR or kidney problem?

Yes No
This document is intended to serve as confirmation of informed consent for IV therapy as ordered by the provider at Replenish IV Hydration & Wellness LLC
(Initial) I have accurately documented any known allergies to drugs or other substances, or of any past reactions to anesthetics. *
(Initial) I have accurately documented all current medications and supplements. *
(Initial) 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 to give my informed consent.
Side Effects/Risks
(Initials) blanks* I understand that:
The procedure involves inserting a needle into a vein and injecting the prescribed
solution or injecting a solution into a muscle.

Alternative to intravenous/injectable therapy are oral supplementation and / or dietary
and lifestyle changes.

Risks of intravenous/Injectable therapy are included but not limited to:
a. Occasionally to commonly:
i. Discomfort, bruising and pain at the site of injection.
ii. General feeling of warmth during and after injection b. Rarely:
i. Inflammation of the vein used for injections, phlebitis, metabolic disturbances, and injury
ii. Reactive Hypotension (or rapid drop in blood pressure) iii. Reactive Hypoglycemia (or rapid drop in blood sugar)
c. Extremely Rarely: Severe allergic reaction, anaphylaxis infection, cardiac arrest and death.
Benefits of intravenous/injectable therapy include:
Injectables are not affected by stomach or intestinal absorption problems.

The total amount of infusion is available to the tissues.

Nutrients are forced into cells by means of a high concentration gradient.

Higher doses of nutrients can be given than possible by the mouth without
intestinal irritation.
The Procedure
The IV intravenous procedure involves inserting a needle into your vein and infusing IV fluids over a determined period of time or prescribed nutrients (vitamins, minerals, amino acids). Your vitals will be measured prior to and after your infusion.

The injectable procedure involves injecting a small amount of solution into a muscle with a needle. The needle is inserted to inject the vitamins and then removed.
What Safety Precautions Must You Take?
- Monitor the insertion site for signs and symptoms of infection (redness, swelling, discharge). Notify the clinic immediately. If your experience a sustained fever greater than 101, do not delay treatment and go to the ER as this can be a sign of sepsis.
- If you experience any side effects the infusion will be stop. It will be determined if you can restart at a lower rate or if your infusion needs to be discontinued. For sever symptoms staff will make a call to 911.
My Consent for Nutrient Infusion Therapy is Voluntary
(Initials) blanks* My request for nutrient infusion therapy as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse treatment at any time.
Statement of Person Giving Informed Consent
I have read this consent form and understand the information that it contains. I understand the risks, benefits and effects. I have had the opportunity to have all my questions answered to my satisfaction. I do not expect the provider(s) to anticipate and or explain all the risk and possible complications that couls arise. i rely on the provider(s) to excerise judgment during the course of treatment with regards to my procedure. I understand that i have the right to consent or refuse any proprosed treaments/services at any time. My signature on this form affirms that i give consent for IV/IM Nutrient Therapy.
Financial
I understand that Replenish Hydration and Wellness does not accept Insurance. Replenish Geatly apppericates payments in full at the end of your service. Acceptable forms of payment are Cash, Cashapp, Zelle, Venmo, Debit/Credit Cards and HSA/Flex Spending cards.
Confidentiality
All information regarding the nature of your treatment is maintained by Replenish. We follow HIPAA regulations and maintain confidentiality.Your imformation is considered confidential with the office unless specified by you in writing. Records can be sent to your primary care proviser if requested.
Please initial statement below
blanks*I acknowledge that I have read and understand all of the forgoing statements and that my signature below indicates that I agree to abide by all the above conditions.
Signature of Patient *

Clear
Date *

Month Day Year
Date
Signature of Parent or Guardian

Clear
Date

Month Day Year
Date
RELEASE OF MEDICAL INFORMATION
I hereby authorize Replenish to disclose my medical records, to EMS, my spouse, and
emergency contact. I also authorize Replenish to discuss my care and share my medical information with my primary care physician for the purpose of monitoring, quality control or safety concerns.
Signature of Patient *

Clear
Date *

Month Day Year
Date
Signature of parent or Guardian

Clear
Date

Month Day Year
Date
MD Intial
Should be Empty:

Intake & Consent Form

Side Effects/Risks

Benefits of intravenous/injectable therapy include:

The Procedure

What Safety Precautions Must You Take?

My Consent for Nutrient Infusion Therapy is Voluntary

Statement of Person Giving Informed Consent

Financial

Confidentiality

Please initial statement below

RELEASE OF MEDICAL INFORMATION