Patient Medical History Form

Patient Health History and IV Hydration Therapy Consent

Please provide detailed information about your health background and review the consent statement for IV Hydration Therapy. Your signature and date at the end of the form are required for consent.
Medications
Current Health Issues and Diagnoses
Recent Date of Lab Work/Abnormal Results
Current Weight (in pounds)
Current Height (in feet and inches)
History of Procedures and Surgeries
Consent for IV Hydration Therapy

IV Hydration Therapy involves the administration of fluids, vitamins, and minerals directly into the bloodstream to help improve hydration and overall wellness. While many patients benefit from this therapy, there are potential risks including infection, vein irritation, and allergic reactions. Please review the information carefully and provide your consent below.
Patient Signature for Consent*
Date*

MonthDayYear
Date
Should be Empty:

Patient Health History and IV Hydration Therapy Consent