IV Me Now FL - Medical History & Consent for Methylene Blue Infusion
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1. Screening for Contraindications
Please answer the following questions honestly. Your safety depends on accurate information.
Medical Conditions (check all that apply)
I have G6PD deficiency (Glucose-6-Phosphate Dehydrogenase Deficiency)
I have severe kidney (renal) disease or impairment
I have liver disease or dysfunction
I am currently pregnant
I am currently breastfeeding
I have a known allergy to methylene blue or thiazine dyes
I have uncontrolled high blood pressure
I have seizure disorder
I have had serotonin syndrome in the past
2. Current or Recent Medications
Are you currently taking any of the following (within the past 6 weeks)?
Type a question
SSRI (e.g., Prozac, Zoloft, Lexapro, Paxil, Celexa)
SNRI (e.g., Effexor, Cymbalta)
MAOI (e.g., Nardil, Parnate)
TCA (e.g., Amitriptyline, Nortriptyline)
Buspirone
Lithium
Dextromethorphan (in cough medicine)
Tramadol
St. John’s Wort
5-HTP or L-Tryptophan supplements
Any psychedelic substance (MDMA, LSD, psilocybin, etc.)
Linezolid or other serotonergic antibiotics
Other antidepressant or serotonergic drugs:
*
Note: Combining methylene blue with serotonergic drugs increases the risk of serotonin syndrome, which can be life-threatening. If you’ve taken any of the above within the last 5 weeks (especially Prozac), you are not eligible at this time.
3. Informed Consent
Are you currently taking any of the following (within the past 6 weeks)?
Please read and acknowledge the following terms by checking every item
*
I understand that methylene blue is a potent MAOI and may cause serious interactions if combined with serotonergic medications or supplements.
I have disclosed all current medications and supplements, including recreational or psychedelic use.
I understand that methylene blue may cause temporary discoloration of urine, skin, or mucous membranes (blue/green color).
I understand that side effects may include headache, nausea, increased blood pressure, dizziness, or allergic reaction.
I understand that if I become pregnant or start any new medications, I must inform my provider before receiving this therapy.
I have had the opportunity to ask questions and have them answered to my satisfaction.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: