Consent For Treatment & Medical History Form

Full Name of Client*

First NameLast Name

Date of Birth

Gender

MaleFemalePregnant

Phone Number*

Address

Street Address

CityState / Province

Postal / Zip Code

Check any medical conditions that apply to you:*

please list any other medical conditions if not listed above

Are you currently taking any medication?*

YesNo

if yes, please list

Do you have any medication allergies?*

YesNo

if yes, please list allergy and reaction

Type of IV

Date of Service

Date

Time Frame (more options the better)

My signature below confirms that:

1. I understand the information provided on this form and agree to all statements made above.

2. Intravenous infusion therapy has been adequately explained to me by Registered Nurse/ or physician and understand the risks and benefits involved.

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

4. I authorize and consent to intravenous (IV) infusion therapy.

5. I release Dr. Azizad, Drip Lab IV inc., and all medical staff from all liabilities for any complications or damages associated with my IV infusion therapy.

Signature