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., all medical staff, and Legacy HC, LLC dba Legacy Concierge from all liabilities for any complications or damages associated with my IV infusion therapy.

Signature