IV/IM Therapy Client Consent Form

IV/IM Therapy Client Consent Form

IV/IM Therapy by TwoSisters Ethereal Med Spa
Patient Information
Name*

First NameLast Name
Birthday*

MonthDayYear
Input your birth date
Age*
Your current age. e.g., 32
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name
Phone Number
Please enter a valid phone number.
How did you find us?

I understand that IV/IM therapy should not be used in patients with severe allergies, a history of anaphylaxis, or history or presence of multiple severe allergies or hypersensitivity to any of the ingredients in the vitamin mix, including glutathione. I have disclosed to my healthcare team any history of severe allergies or anaphylaxis that I have had and understand that failure to do so could result in serious bodily injury or death.*
Put your Initials
I understand and accept that IV/IM therapy carries with it both risks and benefits and I acknowledge that it is not possible for the healthcare team at LQV to screen me for each and every condition which could potentially interact with the IV/IM therapy in a negative way and hereby agree to hold LQV harmless from any and all injuries I sustain while undergoing IV/IM therapy.*
Put your Initials
I have been advised by members of the healthcare team that alternatives to IV/IM therapy include but are not limited to diet, exercise, and consuming sports drinks/water as well as doing nothing at all.*
Put your Initials
MANDATORY MEDIATION

If a dispute between the parties arises out of or relates to this agreement, the breach thereof, or any performance or obligation due hereunder, and ifthe dispute cannot be settled through direct negotiation, the parties agree first to try in good faith to settle the dispute by mediation administeredby the American Arbitration Association under its Commercial Mediation Rules before resorting to arbitration, litigation, or some otherdispute resolution procedure.
WAIVER OF JURY TRIAL

YOU HEREBY KNOWINGLY, VOLUNTARILY, INTENTIONALLY AND IRREVOCABLY WAIVE THE RIGHT TO A TRIAL BY JURY WITH RESPECT TO ANYLITIGATION ARISING OUT OF THIS AGREEMENT, RELATING TO THE PERFORMANCE OF THE ABOVE-DESCRIBED PROCEDURE, OR ANY OTHERDISPUTE OR CONTROVERSY BETWEEN YOU AND LQV.
INFORMED CONSENT

Your consent for this procedure is strictly voluntary. By signing this informed consent form, you hereby grant authority to your provider to perform IV/IM therapy and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition. The nature and purpose of this procedure, with possible alternative methods of treatment as well as complications have been fully explained to your satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment.I have read this informed consent and certify that I understand its contents in full. I hereby give my consent to this procedure and have been asked tosign this form after my discussion with the provider.
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE RISKS ASSOCIATED WITH THE PROCEDURE. I AM SATISFIED WITH THE EXPLANATION I HAVE RECEIVED AND AM ELECTING TO PROCEED WITH IV/IM THERAPY.
Patient Signature

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Date

MonthDayYear
Date
Witness Signature

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Date

MonthDayYear
Date
Should be Empty:

	Yes	No
Congestive Heart Failure?
Severe Renal Impairment?
Heart Attack / Stroke?
Condition of Sodium Retention or Electrolyte Imbalance?
Edema Water Retention?
High / Low Blood Pressure?
Severe Frequent Headaches?
Fainting / Seizures / Epilepsy?
Diabetes / Low Blood Sugar?
Any liver conditions? (e.g. Liver Cirrhosis, Liver Disease)
Any allergies? If yes, please list here.
Do you have Sulfa Allergies?
Do you have or have had asthma?

IV/IM Therapy Client Consent Form

Patient Information

Medical Questionnaire for Nutrient IV/IM Therapy

MANDATORY MEDIATION

WAIVER OF JURY TRIAL

INFORMED CONSENT

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE RISKS ASSOCIATED WITH THE PROCEDURE. I AM SATISFIED WITH THE EXPLANATION I HAVE RECEIVED AND AM ELECTING TO PROCEED WITH IV/IM THERAPY.