IV Hydration and Vitamin Therapy/Injection Informed Consent Form
You are being offered IV Hydration and Vitamin Therapy, which involves the administration of fluids and vitamins directly into your bloodstream or a subcutaneous or intramuscular injection. This treatment can help with hydration, recovery, and overall wellness.
Personal Information
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First Name
Last Name
Date of Birth
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Email
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Format: (000) 000-0000.
Today's date
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1. Purpose of IV Hydration and Vitamin Therapy
To enhance hydration levels, to provide essential vitamins and minerals, to aid in recovery from illness or fatigue and to improve overall health and wellness.
2. Potential Benefits
Increased energy levels, enhanced hydration, improved recovery time after exercise or illness and boosted immune function.
3. Possible Risks and Side Effects
While IV therapy is generally safe, some potential risks include: Pain or swelling at the injection site, infection at the injection site, Allergic reactions to vitamins or medications and Fluid overload (rare).
4. Important Disclaimers
We do not claim to cure any medical condition. This therapy is not a substitute for regular visits to your primary care physician (PCP). We are not responsible for any adverse effects or complications arising from your treatment.
5. Consent for Treatment
I understand the purpose, benefits, and potential risks associated with IV Hydration and Vitamin Therapy. I have had the opportunity to ask questions and have received satisfactory answers.
I consent to receive IV Hydration and Vitamin Therapy:
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Yes
No
6. Media Release
I give permission for Dripping Wellness to use photographs or videos taken during my treatment for promotional purposes, including social media and website content.
Media Release Consent:
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Yes
No
7. Acknowledgment
I acknowledge that I have read and understood this consent form. I have had the opportunity to discuss my treatment with a qualified healthcare provider and understand that I can withdraw my consent at any time.
Patient's Signature
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