IV VITAMIN THERAPY CONSENT FORM

IV VITAMIN THERAPY CONSENT FORM
PERSONAL INFORMATION
Full Name : (PLEASE USE CAPITAL)*

First NameLast Name
Date*

MonthDayYear
Date
Gender:

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
MEDICAL HISTORY
Please list any known allergies
Do you have any existing medical conditions? If yes, please specify:
Have you previously received IV vitamin therapy? If yes, please describe your experience:
Are you pregnant or breastfeeding?

YesNo
Do you have any concerns or questions about the IV vitamin therapy procedure?
IV VITAMIN THERAPY EXPLANATION
IV Vitamin Therapy Explanation:
I, the undersigned, understand that IV vitamin therapy involves the administration of vitamins, minerals, and other nutrients directly into my bloodstream through an intravenous (IV) line.

This method of delivery may be used to address various health concerns or to enhance overall wellness. I acknowledge that the specific nutrients, dosages, and treatment plan will be determined by the healthcare provider based on my individual needs and goals.

Risks and Benefits:
I understand that IV vitamin therapy has potential benefits, including increased energy, improved hydration, and enhanced nutrient absorption. However, I also acknowledge that there are potential risks, such as infection, allergic reactions, and vein irritation. The healthcare provider has explained these risks to me, and I
have had the opportunity to ask questions.

Consent for Treatment:
I voluntarily consent to receive IV vitamin therapy as recommended by the healthcare provider. I understand that the treatment plan may be adjusted based on my response and progress. I agree to inform the healthcare provider of any changes in my medical history, medications, or health status that may affect my treatment.

Financial Responsibility:
I understand that I am responsible for the cost of the IV vitamin therapy treatment. I have been informed of the fees associated with this service and agree to pay for the treatment at the time of service.

Confidentiality:
I acknowledge that my medical information and treatment records will be kept confidential in accordance with applicable laws and regulations.
Patient Signature*

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Date*

MonthDayYear
Date
Healthcare Provider Statement:
I have discussed the risks, benefits, and alternatives of IV vitamin therapy with the patient. I believe that the potential benefits outweigh the risks, and I recommend this treatment based on the patient's medical history and need.
Healthcare Provider Signature:*

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Date*

MonthDayYear
Date
THANK YOU FOR ENTRUSTING US WITH YOUR CARE, AND WE LOOK FORWARD TO ASSISTING YOU ON YOUR PATH TO IMPROVED HEALTH AND WELLNESS.
INTAKE FORM
PERSONAL INFORMATION
Full Name: (PLEASE USE CAPITAL)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
EMERGENCY CONTACT
Full Name*

First NameLast Name
Relationship*
Phone Number*
HEALTH INFORMATION:
Primary Care Physician:*

First NameLast Name
Physician's Phone number:*
Pharmacy Name:*
Pharmacy Phone number:*
Current Medications and Supplements:(List all) Include Medication/Supplement, Dosage & Frequency
Allergies: (List all, including food and drug allergies)
Existing Medical Conditions:(e.g., diabetes, hypertension) include Diagnosis Date:
Reason for IV Therapy: (e.g., energy boost, hydration, immune support)
Have you previously received IV vitamin therapy? if yes, please provide details
Are you pregnant or breastfeeding?

YesNo
Please describe your current overall health and any specific health goals:
CONSENT:
I, the undersigned, certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that the information will be used to provide me with appropriate IV vitamin therapy and will be kept confidential in accordance with applicable laws and regulations.
Patient Signature*

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Date*

MonthDayYear
Date
THANK YOU FOR ENTRUSTING US WITH YOUR CARE, AND WE LOOK FORWARD TO ASSISTING YOU ON YOUR PATH TO IMPROVED HEALTH AND WELLNESS.
Healthcare Provider Signature*

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IV VITAMIN THERAPY CONSENT FORM

PERSONAL INFORMATION

MEDICAL HISTORY

IV VITAMIN THERAPY EXPLANATION

INTAKE FORM

PERSONAL INFORMATION

EMERGENCY CONTACT

HEALTH INFORMATION:

CONSENT: