INFORMATION AND CONSENT FOR IV THERAPY INJECTIONS

INFORMATION AND CONSENT FOR IV THERAPY INJECTIONS
Patient Name:*
Date:*

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At AvLa Medspa we would like to provide the highest standards and service in IV therapy and vitamin Injection. We have policies and protocols in place to identify higher risk patients who may benefit from higher levels of medical care. Due to our measures some clients may not be able to receive our therapy. We thank you in advance for understanding the measures we take to allow for the best and safest experience.

This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, improving fatigue, etc. We offer no diagnostic testing, we make no medical advice or diagnoses. This procedure may be considered medically unnecessary. It may or may not reduce, or cure the condition for which it has been prescribed; However, this therapy has been recommended to you in the belief that it is of potential benefit and its use will most likely improve your condition and your overall health.

The principal side effects that may accompany intravenous administration of nutrients include:
- Burning and stinging at the site of infusion or if IV infiltrates into surrounding tissue
- Muscular spasms, weakness, or fatigue
- Allergic reactions (rare)
- Local thrombophlebitis (very rare
- Small scaring at insertion site. (Small dot)
- Dizzines, (Usually due to low blood sugar) We recommend all clients to have eaten something small prior to treatment.
By signing below you certify that you understand and agree with the following statements.
- I certify that I am not intoxicated or under the influence of any other mind altering substances at the time of receiving my IV therapy/booster shots.
- I understand that the AvLa Medspa Nurses have the right to refuse or terminate my infusion at any point and that I must comply with the instructions whilst receiving and after the infusion.
- I understand that not all people react in the same way to medication and that whilst most feel better after therapy, there is no guarantee that I will feel the same way.
- I certify that I am at least 18 years old.
- I understand the risk of IV cannula insertion to include localised pian, bleeding, bruising, blood clots, infections (phlebitis), and local soft tissue injury and I understand to seek immediate medical attention if such complications arise.
- I understand that having IV Therapy may stimulate the immune system and detoxification pathways and this can cause symptoms such as fever, fatigue, headaches and nausea.
- I understand that AvLa Medspa needs to be able to safely store my private information and I hearby give consent to all employees at Vitality Oslo to keep an updated journal of my treatments.
I have read and understand the above:
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MEDICAL HISTORY QUESTIONNAIRE
PATIENT INFORMATION
First Name: Last Name: .
Name

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Date of Birth . Home Address .
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Home Address
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Email:
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Emergency Contact: phone number: .
Emergency Contact:
phone number:
Please complete the following questionnaire to the best of your ability. All information is strictly confidential.
REASON FOR TREATMENT
1.) Please tell us why you are seeking treatment?
2.) Have you ever had IV Therapy before? If yes, what type and how long ago?
3.) Have you had any problems with IV Therapy or Injections?
4.) Please list any medical conditions you have had or currently have:
5.) Do you have a history of heart or lung problems?
6.) Have you ever been diagnosed with high blood pressure?
8.) Do you have a history of kidney problems?
9.) Do you have a history of liver problems?
10.) Please list any surgical procedures you have had in the past
11.) Please list ALL medications, supplements, or vitamins you are currently taking:
ALLERGIES
12.) Have you ever had an allergic reaction to medication?
13.) Do you have any allergies to sulphur?
14.) Are you or could you be pregnant?
15.) Are you currently breastfeeding?
16.) Do you have any history of cancer?
I, the undersigned, do hereby agree and give my consent for Laura Ashley Moore, registered nurse, and other AvLa Medspa employees under her supervision, to provide alternative medical care and treatment that I have requested in the form of intravenous or intramuscular nutrient/vitamin injections. I understand that Laura Ashley Moore uses alternative treatment methods and I have chosen to explore this approach.

I certify that the preceding medical and personal history statements are true and correct. I am aware that it is my responsibility to inform the provider of my current medical or health conditions and to update this history. A current medical history is essential for the provider to execute appropriate treatment procedures.

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INFORMATION AND CONSENT FOR IV THERAPY INJECTIONS

I have read and understand the above:

MEDICAL HISTORY QUESTIONNAIRE

PATIENT INFORMATION

REASON FOR TREATMENT

ALLERGIES