IV Me Now FL - Methylene Blue Medical History and Consent

IV Me Now FL - Medical History & Consent for Methylene Blue Infusion
Personal Information
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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 impairmentI have liver disease or dysfunctionI am currently pregnantI am currently breastfeedingI have a known allergy to methylene blue or thiazine dyesI have uncontrolled high blood pressureI have seizure disorderI 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)BuspironeLithiumDextromethorphan (in cough medicine)TramadolSt. John’s Wort5-HTP or L-Tryptophan supplementsAny 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.
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IV Me Now FL - Medical History & Consent for Methylene Blue Infusion

Personal Information

1. Screening for Contraindications

2. Current or Recent Medications

3. Informed Consent