Consent & Treatment Record

Date of Service

Date

Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DOB*

DOB

Date of Birth

MonthDayYear

Age

Date of Birth

Phone Number

E-mail*

example@example.com

Prior Consent?

I have previously completed a consent form, and by checking this box, I affirm that nothing from my previous consent or medical condition has changed (if unsure, leave this box unchecked).

Are you 18 years of age or older?*

YesNo

Do you have any health conditions or concerns?*

YesNo

Please provide details

Current Medications

Allergies:*

NKA

Past Medical History (check all that apply)*

Please provide details on medical history

Are you currently pregnant or breastfeeding?*

YesNoN/A

Any concerns you would like to discuss with the nurse?*

YesNo

Patient Consent to Treatment
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS

I, the undersigned, do hereby request and consent to an evaluation and treatment by Revive IV Hydration and its staff (“Practice”). I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during the course of treatment. I will inform the Practice of any sensitive areas or adverse conditions that I may have had prior to, during or after treatment. I intend this consent to cover the entire course of treatment.
I understand that any questions I may have regarding the potential side effects, complications, treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment.
I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.
I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of my treatment at the Practice.

Photo Consent

I authorize Revive IV Hydration to photograph, videotape, or record me and agree that the images, video, or recordings may be used for medical reasons (including training, education, or research). I hereby release Revive IV Hydration, its employees, clinicians, or other authorized persons from any responsibility which might arise from the taking and authorized use of such images, video, or recordings.

Patient Signature*

Clear

After signing, please let our staff know you have completed the consent.