Ject Medical Aesthetics - IV Infusion Consent Form

Name: Dr Ryan Harvey

Address: 35 Ferry St, Kangaroo Point QLD 4169

Phone: 07 3303 0859

Prescriber No: 2445528
Date

MonthDayYear
Date
CLINIC DETAILS

RN Name: Hayley Bonomi

Company Name: Ject Medical Aesthetics

Address: Suite 2/ 53 Margaret Street, Toowoomba, QLD, 4350

Phone: 0409 579 643
Patient Name
Email Address
example@example.com
Address
Date of Birth

MonthDayYear
Date
Phone
Please Indicate if you suffer or have suffered from any of the following conditions

Congestive Heart FailureHeart disease or other heart conditionsMetabolic alkalosisSickle-cell anaemiaGlucose-6-phosphate dehydrogenase (G6PD) deficiencyDiminished renal function or any other kidney problemsIschemic StrokeLiver disease as consequence of alcoholism or severe reduction in kidney functionHypersensitivity to sodium lactateExtracellular hyper hydration or hypervolemiaUncompensated cardiac failureHypercalcemia or HyperkalaemiaAscetic cirrhosis or severe metabolic acidosisConditions associated with increased lactate levels (hyperlactamia) including lactic acidosis, or impaired lactate utilization, such as severe hepatic insufficiencyConcomitant digitals therapyNone of the above
Any other aspects of your health that you think we should know about
Ever had an allergic reaction to an intravenous vitamin therapy

YesNo
List an allergies or any information we should know that may be relevant to treatments you will be given
Any current medications s including OTC medications and vitamin mineral supplements
Any major illnesses If yes please provide details
Currently Pregnant or breast feeding?

YesNo
Script*
Nurse Signature

Clear
Date

MonthDayYear
Date
Dr Ryan Harvey, Physician Prescribing No 2445528, Address 35 Ferry Street Kangaroo Point QLD 4169
Doctor Signature

Clear
Date

MonthDayYear
Date
Should be Empty: