Client Consent and Medical History Form

Client Consent and Medical History Form

Please complete this form to provide your medical history and consent.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Date
Email Address
example@example.com
Phone Number

Area CodePhone Number
By completing this questionnaire, you will assist us in evaluating you and your specific concerns. The information you provide will be used to determine what factors may be affecting you so that we may recommend the correct treatment plan.
Do you have any allergies?
Please list any current medications that you have been prescribed by your GP:
Please list any non-prescriptive/over the counter medicine:
Do you have any chronic illnesses or medical conditions?
Please tick any health conditions which you have previously or currently experience:

AllergiesArthritisCancerSmokingPregnancy/breast feedingAlcoholismEpilepsyPacemaker/heart diseaseLow blood pressureHigh blood pressureKidney Disease/disordersDiabetesHormonal DisordersUnderactive ThyroidOveractive ThyroidRecent surgeryOther
Have you ever been hospitalised or under the care of a doctor in the past month?
Do you currently take blood thinners?
Do you currently take or use any type of steroids?
Are you pregnant?
Are you currently breastfeeding?
If you answered ‘Yes’ to any of the above questions 1-5, you may be advised by your practitioner that you cannot receive any IV fluids and you may be denied services. I understand that participating in the intravenous (IV) hydration and vitamin administration services provided by Doctor Wellness and Partners carries risks.
Choice of IV/IM Vitamins

B complexVitamin CMagnesiumB12Folic AcidVitamin EVitamin AVitamin DGlutathioneBiotinNAD+
Vitals

If known please enter
Temperature
Blood Pressure
Heart Rate
Lifestyle
How many hours do you sleep?
How often do you exercise?
On a scale of 1 (low) to 10 (high), How would you rate your stress levels?
Nutrition

Please indicate the frequency of these foods consumed on a weekly basis:
Sugar:
Spicy Foods
Salty Foods
Fast Food
I have truthfully answered all questions regarding my medical history and have informed the practitioner about any and all prescription medications and/or over the counter drugs I take, as well as any street or recreational drugs. I understand that failing to inform the practitioner about my medical issues and/or drug use can lead to serious complications.

I acknowledge that I am responsible for any medical care I may have that is directly or indirectly related to the services provided by Doctor Wellness and Partners. If I seek medical treatment for any side effects or reaction, it will be at my own expense.

I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my voluntary participation in Doctor Wellness IV services rests entirely with me if I fail to disclose any of my health condition(s), medications, or drug use in advance of the services provided. I expressly represent and warrant to Doctor Wellness and Partners that I have never been diagnosed with or treated for any illnesses or conditions that may result in increased risk when participating in the services provided by Doctor Wellness and Partners. I understand that Doctor Wellness and Partners bear no responsibility for and will not screen for, diagnose,monitor, or provide any care for such conditions. I acknowledge that Doctor Wellness and Partners relies upon information provided by me in assessing my suitability to participate in the services provided.
There is no guarantee that hydration therapy will temporarily or permanently cure or resolve your hangover, effects of altitude sickness, dehydration, or viral illness. Please drink alcohol in moderation. Heavy drinking after hydration therapy can lead to stomach irritation or other complications. Hydration therapy is not a cure for heavy drinking. Excessive drinking can lead to alcohol poisoning and other serious medical problems. Always drink alcohol in moderation.

I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedures. I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that the practitioner to anticipate or explain all associated risks. I waive any and all claims related to the services provided and agree to hold Doctor Wellness and Partners harmless regarding any complications or consequences I experience during or following the service.

This document is intended to serve as confirmation of informed consent for IV therapy as ordered by the practitioner. I have informed the practitioner of any known allergies to drugs or other substances, or of any past reactions to anaesthetics. I have informed the practitioner of all current medications and supplements.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. I understand that:

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution .

2.   Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.

3.   Risks of intravenous therapy include but not limited to:

A.   Occasionally to commonly: Discomfort, bruising and pain at the site of injection.

B.   Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

C.   Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

4.   Benefits of intravenous therapy include:

A.   Injectables are delivered directly into the bloodstream, and therefore do not affect the stomach, or intestinal absorption.

B.   Full dose is absorbed by infusion. Nutrients are absorbed into cells by means of a high concentration gradient. Although higher doses of nutrients have been given orally without intestinal irritation, absorption rate remains low and is limited by intestinal absorption.

I am aware that other unforeseeable complications could occur. I do not expect the practitioner to anticipate and/ or explain all risk and possible complications. I rely on the practitioner to exercise judgment during my procedure. I understand the risks and benefits of the procedure, and have had the opportunity to have all my questions answered. I understand that I have the right to consent or refuse any proposed treatment at any time prior to its performance.
GDPR & Data protection

I understand that my information will be kept strictly confidential and will not be shared with anyone but with Doctor Wellness and Partners. By signing below I am agreeing to information being shared with Doctor Wellness and Partners.

My signature on this form affirms that I have given my consent to IV therapy with any different or further procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

My signature below constitutes my achknowledgment that:

(1) I have read, understood and fully agree to the foregoing and I have received and read the pre and post care treatment information document.

(2) Give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information that I desire.

(3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.
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Client Consent and Medical History Form

Vitals

Lifestyle

Nutrition