IV Hydration Intake Form & General Treatment Consent Form

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Allergies

Current Medications

Are you experiencing Shortness of Breath?

Have you recently or are you currently experiencing any bleeding?

Have you recently or are you currently experiencing any chest pain?

Have you recently or you are currently experiencing any edema or leg swelling?

Emergency Contact name, phone number, & relationship

Signature

Issa Selflove Oasis reserves the right to refuse to initiate or continue any treatment at any time-based on the RN discretion. By signing below, I hereby agree that all of the above information is true andaccurate to the best of my knowledge

Thank you for choosing Issa Selflove Oasis, for your wellness needs.Please read this consent form carefully to understand the services we provide, the associated risks, and your rights as a client.

At Issa Selflove Oasis, we offer the following treatments:

IV Hydration Therapy:IV hydration therapy involves administering fluids, electrolytes, vitamins, and nutrients directly into your bloodstream through a sterile intravenous catheter. This method is designed to replenish hydration, support recovery, and enhance overall well-being.
Vitamin Injections: Vitamin injections deliver essential vitamins and nutrients intramuscularly or subcutaneously. These injections are intended to provide a quick and effective boost for energy,immunity, and other wellness benefits.

Potential Benefits

Improved hydration and energy levels.
Enhanced immune support and recovery.
Increased absorption of essential nutrients.
Symptom relief from fatigue, jet lag, or dehydration.
Potential Risks and Side Effects

While our services are generally safe, they may involve some risks, including:

Minor bruising, redness, or soreness at the injection or IV site.
Temporary dizziness, lightheadedness, or nausea.
Rare but potential allergic reactions to ingredients.
Infection at the site of administration (very rare with proper care).

Client Acknowledgment and Responsibilities:

By signing this consent form, you acknowledge and agree to the following:

I understand that the services provided by Issa Selflove Oasis are elective and not a substitute for medical treatment.
I have disclosed my full medical history, including allergies, medications, and existing medical conditions, to the provider.
I understand that results may vary, and Issa Selflove Oasis makes no guarantees about the outcome of treatments.
I will follow all pre- and post-treatment instructions provided by Issa Selflove Oasis.

Consent to Treatment:

I hereby consent to receive IV hydration therapy and/or vitamin injections from Issa Selflove Oasis.
I understand the nature of the services, potential risks, and benefits. I have had the opportunity to ask questions and have received satisfactory answers.

Cancellation and Rescheduling Policy:

At Issa Selflove Oasis, we value your time and health. To ensure a seamless experience for all our clients, we have implemented the following cancellation and rescheduling policy:

1.Cancellations & Rescheduling:

If you need to cancel or reschedule your appointment, you may do so up to 24 hours prior to the scheduled time for a full refund or no charge.
Cancellations made within 24 hours of the appointment will incur a $15 fee, with the remainder refunded.

2. Inability to Provide Services: In the rare event we cannot administer the service due to circumstances such as:

Difficulty accessing veins (hard stick clients)
Vital signs outside the safe parameters
Medical conditions contraindicating treatment.

A 25% administrative fee will be applied, and the remaining amount will be refunded promptly. Your health and satisfaction are our top priorities. If you have any questions about this policy, please don’t hesitate to contact us.

By signing below, I voluntarily agree to proceed with treatment and release Issa Selflove Oasis and its staff from liability for any adverse outcomes arising from my treatment, provided all procedures areperformed appropriately. I also acknowledge and agree to Issa Selflove Oasis cancellation and rescheduling policy, which requires advance notice for any appointment changes. I understand that last-minute cancellations or missed appointments may be subject to fees in accordance with the company’s policy.

Client Name

First NameLast Name

Client Signature

Date

Legal Disclaimer Issa Selflove Oasis is committed to providing safe and professional services. However, the treatments provided are not intended to diagnose, treat, cure, or prevent any disease and should not beconsidered a replacement for medical advice or care from a licensed physician.

By signing this form, the client agrees that any claims or disputes arising from the services provided will be resolved through binding arbitration under the laws of the State of Florida, and liability for any damages shall be limited to the cost of the services rendered.

Note: If you have any questions or concerns, please do not hesitate to ask our team before proceeding with treatment.