Mobile IV Therapy 2U H&P and Consent

Mobile IV Therapy 2U H&P and Consent
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

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Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
Primary Healthcare Provider's Name
Primary Healthcare Provider's number
Medical History
Do you have any known allergies to medications, foods, or other substances?
Weight
Do you have any of the following medical conditions? Select all that apply

CancerDiabetesMyasthenia GravisHigh Blood PressureHepatitisKidney DiseaseCHFLeber's optic neuropathyKidney stonesLiver DiseaseEpilepsySubstance AbuseDepressionLong HaulChronic PainHypotensionLyme DiseaseAutoimmune DiseaseNone of the above
Past surgeries and dates
Other medical diagnoses
Current medications, including supplements and OTC
Are you pregnant or breastfeeding?

YesNo
The CLIENT is responsible for consulting their own physician or healthcare provider for any medical advice, diagnosis, or treatment. It is the CLIENT’s responsibility to verify with their healthcare provider whether they are an appropriate candidate for IV hydration therapy. The CLIENT must fully disclose all known medical conditions to Mobile IV Therapy 2U LLC. The CLIENT understands that failing to provide complete and accurate medical information may significantly increase the risk of serious complications, injury, or death related to IV hydration, intramuscular (IM) injections, and any associated services. Inaccurate or incomplete disclosure of medical history heightens the possibility of adverse outcomes. By signing below, you affirm that the information you have provided regarding your current and past medical conditions is truthful, complete, and accurate. You acknowledge that you have no known allergies, intolerances, or sensitivities to the therapies discussed and mutually agreed upon with the nurse administering your treatment today. You understand that your medical information will be reviewed by a medical director to ensure your eligibility under standing orders and established protocols. Furthermore, by submitting your health information, you acknowledge that no prescription will be issued without full disclosure of your primary healthcare provider's name and contact information. Please note: Mobile IV Therapy 2U LLC does not diagnose medical conditions, provide medical advice, or dispense controlled substances. You agree to hold harmless all physicians, pharmacies, and pharmacy affiliates involved with your care for any health issues unrelated to services rendered. As with any wellness program, outcomes are not guaranteed, and individual results may vary. Prescription medications are non-refundable. Please consult your healthcare provider prior to using any products. The products and services offered are not intended to diagnose, treat, cure, or prevent any disease.

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CLIENT and MOBILE IV THERAPY 2U LLC hereby enter into this agreement for provision of services specified herein (SERVICES). Wherefore, in exchange for consideration, the receipt and sufficiency of which the parties hereby acknowledge, the CLIENT and MOBILE IV THERAPY 2U LLC PROVIDER agree as follows:The CLIENT acknowledges and agrees that this agreement has been entered into BEFORE MOBILE IV THERAPY 2U LLC has provided the SERVICES specified herein to the CLIENT.The CLIENT acknowledges and agrees that this agreement has not been entered into at a time when the CLIENT is facing an emergency or an urgent health care situation.MOBILE IV THERAPY 2U LLC reserves the right to refuse services to the CLIENT for any reason, medical or otherwise.The information provided by MOBILE IV THERAPY 2U LLC, whether on the website, promotional materials, or by PROVIDERS, is for educational purposes only and does not substitute for professional medical advice. All MOBILE IV THERAPY 2U LLC IV hydration products, IM injections, and all other related services and products are not intended to diagnose, treat, cure, or prevent any disease. These statements have not been evaluated by the Food and Drug Administration. The CLIENT assumes all responsibility for using these products and understands that the products are being used voluntarily, with the understanding that no medical advice is implied or expressed through the use of these products. The CLIENT is required to consult with their own healthcare provider or medical professional if they are seeking medical advice, diagnoses, or treatment. The CLIENT is required to consult with their own healthcare provider or medical professional to determine if they are candidates for IV hydration therapy.It is the CLIENT’s sole responsibility to disclose any and all medical conditions to MOBILE IV THERAPY 2U LLC PROVIDERS. The CLIENT understands and acknowledges that significant potential medical complications, injury, or death can arise from IV hydration products, IM injections, and all other related services if the CLIENT does not disclose complete and accurate personal medical information. If the CLIENT fails to provide a full and accurate medical history, and disclose any and all current medical conditions, the potential risk of adverse outcomes, injury, or death is increased, and MOBILE IV THERAPY 2U LLC, its owners, corporate office, and all its PROVIDERS shall be held harmless in such an event.ACKNOWLEDGMENT AND CONSENTMY SIGNATURE BELOW CONSTITUTES MY ACKNOWLEDGEMENT THAT:I HAVE READ AND THE PROCEDURE HAS BEEN ADEQUATELY EXPLAINED BY MY PROVIDER.I AUTHORIZE AND CONSENT TO THE PERFORMANCE OF THE PROCEDURE.TO THE PATIENT AND/OR AUTHORIZED REPRESENTATIVE: You have the right to be informed about your diagnosis or condition and the recommended healthcare service or treatment. This Consent is provided to help you make an informed decision about whether to proceed with the recommended treatment(s) after being informed of potential risks.I specifically authorize and consent to the performance of the following treatment(s): IV therapy and IM injections. These services will be performed by professional medical providers under the supervision of a location-specific medical director. MOBILE IV THERAPY 2U LLC medical personnel will disclose information regarding the risks and benefits of the pharmaceuticals used in their IV hydration products, IM injections, and related services. The CLIENT accepts full responsibility for using these pharmaceuticals after being informed, with the understanding that no medical advice is implied or expressed regarding these products. ADDITIONAL CLIENT ACKNOWLEDGMENTS: The CLIENT acknowledges that the benefits and risks of the treatment(s) — such as IV Therapy, IM injections, and blood draws (phlebotomy) — as well as any alternatives, including declining treatment, have been explained by MOBILE IV THERAPY 2U LLC PROVIDERS. The CLIENT has had the opportunity to ask questions and all questions were answered satisfactorily. The CLIENT acknowledges that serious potential risks exist with treatments provided by MOBILE IV THERAPY 2U LLC. These risks include, but are not limited to: pulmonary embolism, stroke, heart attack, congestive heart failure, kidney injury, anaphylaxis, and severe allergic reactions. Less severe risks may include: infection at the injection site, bleeding, nerve injury, and mild allergic reactions. The CLIENT acknowledges understanding these risks, which have been fully explained. The CLIENT understands that the treatments provided are elective and not intended to cure or prevent any disease. The CLIENT understands that some or all medications administered during treatment may be sourced from a compounding pharmacy. CLIENT consents to the sharing of treatment-related information or records among MOBILE IV THERAPY 2U LLC staff for purposes related to their care and, in case of emergency, with appropriate emergency medical providers. The CLIENT authorizes and consents to the Provider arranging additional necessary treatments deemed clinically appropriate, including but not limited to administration of IV fluids and injections. ATTESTATION AND CERTIFICATION OF INFORMED CONSENT:I certify that: I have had the opportunity to ask any and all questions regarding the proposed treatment(s).All questions have been answered to my satisfaction. I fully understand that I have the right to refuse any service offered. I believe I have adequate information to provide informed consent. I fully understand the clinical implications and potential outcomes of the services offered. By signing below, I affirm that I have read and fully understand this document. I consent to the treatment and hereby affix my signature as authorization for the services described, understanding the associated risks. PATIENT RESPONSIBILITIES TO MOBILE IV THERAPY 2U LLC: The CLIENT agrees to immediately notify the MOBILE IV THERAPY 2U LLC PROVIDER of any discomfort, changes in condition, including but not limited to: dizziness, confusion, pain, redness, swelling, or any other concerning symptoms during treatment. The CLIENT agrees to contact and speak with a MOBILE IV THERAPY 2U LLC professional if they experience any issues or concerns within 72 hours following a treatment.MY SIGNATURE BELOW CONFIRMS THAT:(1) I HAVE READ AND UNDERSTOOD THE INFORMED CONSENT; THE PROCEDURE HAS BEEN THOROUGHLY EXPLAINED BY MY PROVIDER.(2) I AUTHORIZE AND CONSENT TO THE PERFORMANCE OF THE PROCEDURE AND ANY FUTURE REQUESTED PROCEDURES UNDER THIS AGREEMENT.

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Date
Name

First NameLast Name
Rena Apon, Medical Director, has authorized the use of this consent form, permitting a licensed and contracted Mobile IV Thearpy 2U nurse to administer IV therapy and/ or IM injections once the patient has been screened and cleared of any contraindications.
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Mobile IV Therapy 2U H&P and Consent

Medical History