Iv Therapy Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Gender

What is the motivation behind your interest in receiving IV Therapy?

Have you received IV Therapy before?

YesNo

What was your experience like?

Can you provide a list of health conditions or medical concerns to be evaluated for the potential benefits of IV Therapy?

Please check if you have any of the diagnoses below

Date of last Physical Exam/Blood Test

Date

Results of the test

Provide a list of all known and suspected allergies

Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries

Please provide a comprehensive list of all the prescription drugs and supplements you are presently taking, including their respective doses.

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly everyday
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

How did you hear about us?

IV Infusion & Injection Therapy Consent

I understand that intravenous (IV) infusion therapy involves placement of a peripheral IV catheter into a vein for the administration of fluids, vitamins, minerals, amino acids, nutrients, and/or medications. I also understand that injection therapy involves administration of vitamins, minerals, nutrients, and/or medications into the muscle or subcutaneous tissue.

I acknowledge that these therapies are provided by Optimize by JaeNix, PLLC as elective wellness and supportive care and are not intended to replace care from my primary care provider or specialist.

I understand that IV and injectable therapies are intended to support hydration, nutritional status, recovery, and overall wellness, but are not intended to diagnose, treat, cure, or prevent any disease.

I acknowledge that many of the medications, vitamins, minerals, and nutrients used in IV and injectable therapy are prescribed and compounded by licensed pharmacies and may be used off-label, which is a legal and common practice in medicine.

I understand that some of these compounds have not been evaluated by the FDA for specific wellness indications.

I affirm that I have disclosed all of my medical conditions, medications, supplements, allergies, and pregnancy or breastfeeding status to my provider, and I understand that failure to provide complete and accurate information may increase my risk of serious adverse events.

I understand that the procedure involves insertion of a needle into a vein, muscle, or subcutaneous tissue and that common side effects may include pain, bruising, bleeding, swelling, or irritation at the injection or IV site.

I understand that less common risks may include infection, phlebitis, fainting, low blood pressure, fluid overload, electrolyte imbalance, changes in blood sugar, and medication interactions.

I further understand that rare but serious risks may include severe allergic reactions, anaphylaxis, blood clots, sepsis, cardiac events, or death.

I understand that potential benefits of IV and injectable therapy may include improved hydration, increased nutrient absorption, symptom relief, enhanced energy, improved recovery, and overall wellness support, but that results vary and no outcomes are guaranteed.

I understand that unforeseen complications can occur and that I may refuse or stop treatment at any time.I acknowledge that IV and injectable therapy is voluntary and that alternative options include oral supplements, diet and lifestyle modifications, and care from my primary or specialty medical provider.

I confirm that I am choosing to receive IV and injectable therapy voluntarily.I authorize Optimize by JaeNix, PLLC and its medical staff to initiate emergency medical care if necessary during or after my IV or injection treatment.

I certify that I am of sound mind and capable of making medical decisions.

I acknowledge that the nature of the treatment, risks, benefits, alternatives, and potential side effects have been explained to me, and that I have had the opportunity to ask questions and have them answered to my satisfaction.

I understand that there are no guarantees regarding the outcome of treatment.

By signing below, I voluntarily consent to receive IV infusion and/or injectable therapy from Optimize by JaeNix, PLLC.

Signature

Date

IV (Intravenous) Therapy Intake Form

Patient Information