IV Infusion Therapy/Shots Consent Form
Patient Information
Name
*
Age
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Please Select
Male
Female
Non Binary
Prefer not to answer
Email
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance Name
Insurance Policy ID
Insurance Package/Type
Parent/Guardian or Emergency Contact Details
Contact Person Name
*
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Infusion/booster Information:
Treatment location
*
Type of IV Infusion/IM booster
*
Hydration
Hangover
Immune support
Weight loss
Hair growth
Dementia
Anxiety relief
Migraines
Electrolyte replacement
Do you have any known allergies? If yes, then please specify below.
*
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
*
Acknowledgment, Authorization and Waiver
I, the undersigned patient or legal guardian of the patient named above, hereby acknowledge and agree to the following terms and conditions related to the administration of the IV infusion/IM booster treatment:
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1. I understand that IV infusion/IM booster therapy involves the administration of fluids, nutrients, medications, or other substances directly into the bloodstream through a vein or intramuscularly.
2. I understand that the purpose of the IV infusion/IM booster treatment is to provide therapeutic benefits as prescribed by a qualified healthcare professional.
3. I acknowledge that the potential risks and benefits of the IV infusion/IM booster treatment have been explained to me, and I have had the opportunity to ask questions to clarify any concerns.
4. I understand that there may be potential risks associated with IV infusion/IM booster therapy, including but not limited to infection, bleeding, allergic reactions, discomfort, or injury to the vein.
5. I acknowledge that I have been informed of the potential side effects or adverse reactions that may occur during or after the IV infusion/IM booster treatment.
6. I understand that the healthcare provider administering the IV infusion/IM booster treatment will take reasonable precautions to ensure my safety and well-being, but they cannot guarantee the effectiveness or outcome of the treatment..
7. I agree to disclose all relevant medical information, including any known allergies, medical conditions, or medications I am currently taking, to the healthcare provider.
8. I understand that it is my responsibility to inform the healthcare provider of any changes to my health status or medications before each IV infusion/IM booster treatment.
9. I release and discharge the healthcare provider, its employees, agents, and anyone acting under its authority from any liability, claims, demands, or causes of action arising out of or related to the IV infusion/IM booster treatment, except in cases of gross negligence or willful misconduct.
10. I understand that this waiver and release will remain in effect for all current and future IV infusion/IM booster treatments unless revoked in writing.
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Patient/Parent/Guardian Signature: By signing below, I acknowledge that I have read and understood the contents of this IV Infusion/IM booster Waiver Form and voluntarily agree to its terms and conditions.
*
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