INFORMATION AND CONSENT FOR IV THERAPY & INJECTIONS

Patient Name:*

Date of Birth*

Phone Number*

Home Address

City

Postal Code

Email:*

example@example.com

Emergency Contact:*

Phone Number*

Recharge IV provides the highest standards and service in IV therapy and vitamin injections. 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 do not offer diagnostic testing, 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, infiltration into surrounding tissue
Muscular spasms, weakness, or fatigue
Allergic reactions (rare)
Local thrombophlebitis (very rare)
Small scaring at insertion site (rare)
Dizziness, (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 Recharge IV Nurses have the right to refuse or terminate my infusion at any point and that I must comply with the instructions while receiving treatment and after the infusion.
I understand that not all people react in the same way to medication and that while 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.
Pain, bleeding, bruising, blood clots, infections, and local soft tissue injury may occur 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 give consent to Recharge IV to keep an updated journal of my treatments.

Signature*

Today's Date:*

Parent/Legal Guardian Consent, I the undersigned parent or legal guardian of the minor named above, hereby consent to the services provided by Recharge IV and acknowledge that I have read and understood the terms of this consent form.

Parent/ Legal Guardian

First NameLast Name

Please complete the following questionnaire to the best of your ability. All information is strictly confidential.

Please tell us why you are seeking treatment?*

1.) Have you ever had IV Therapy before?*

YESNO

2.) Have you had any problems with IV Therapy or Injections?*

YESNON/A

3.) Please list any medical conditions you have had or currently have:*

4.) Do you have a history of heart or lung problems?*

YESNO

5.) Do you have a history of high blood pressure?*

YESNO

6.) Do you have a history of kidney problems?*

YESNO

7.) Do you have a history of liver problems?*

YESNO

8.) Please list any surgical procedures you have had in the past*

9.) Please list ALL medications, supplements, or vitamins you are currently taking:*

10.) Have you ever had an allergic reaction to medication?*

YESNO

11.) Do you have any allergies to sulphur?*

YESNO

12.) Are you or could you be pregnant?*

YESNO

13.) Are you currently breastfeeding?*

YESNO

14.) Do you have any history of cancer?*

YESNO

I, the undersigned, do hereby agree and give my consent for Esther Garcia, registered nurse, and other Recharge IV 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 Recharge IV 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.

Photo/Media Consent I give permission for my photo/video to be used on social media, websites, and other platforms, with no compensation.*

YESNO

Patient Signature*

Today's Date:*

Nurse signature

Today's Date*

INFORMATION AND CONSENT FOR IV THERAPY & INJECTIONS

PATIENT INFORMATION

I have read and understand the above:

REASON FOR TREATMENT

MEDICAL HISTORY QUESTIONNAIRE

ALLERGIES