Tharpe IV Therapy Intake Form

Tharpe IV Therapy Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Have you received IV Therapy before?
What was your experience like?
Please list all current and past medical conditions
Provide a list of all known and suspected allergies
How did you hear about us?
I voluntarily consent to receive intravenous (IV) hydration therapy provided by Tharpe IV Therapy. I understand that this procedure involves the insertion of a needle into a vein and the administration of fluids and/or vitamins and nutrients.
I understand the following:

- The procedure and its purpose have been explained to me
- Possible side effects include but are not limited to: pain, bruising, bleeding at the injection site, infection, allergic reaction, phlebitis, or vein irritation.
- I understand that although rare, more serious risks can occur, including fluid overload and adverse reactions.
- I agree to inform the provider of any known allergies, medical conditions, or medications I am taking.
- I understand this service is not a substitute for medical care or emergency treatment.
- I acknowledge that results are not guaranteed and may vary.
- I understand that I may refuse or stop treatment at any time.
Date

MonthDayYear
Date
Signature
Should be Empty: