IV History & Consent Form

SOUTHTOWNS COLON HYDROTHERAPY, LLC

DBA Go To Wellness Center
IV VITAMIN & HYDRATION THERAPY

HISTORY & CONSENT FORM
CLIENT INFORMATION
Full Name
Date of Birth

MonthDayYear
Date
Age:
Sex:
Address:
Phone Number:
Email:
example@example.com
Occupation:
Emergency Contact (Name & Phone):
Primary Care Physician:
How did you hear about us?
Have you ever been hospitalized?

YesNo
If "Yes," explain:
Are you currently under a physician’s care?

YesNo
If "Yes," explain:
Conditions
Check all that apply.

High Blood PressureLow Blood PressureHeart AttackHeart DiseaseIrregular HeartbeatKidney DiseaseLiver DiseaseThyroid/Parathyroid DisorderAsthmaSickle Cell AnemiaSarcoidosisLeaky Gut SyndromeAutoimmune DiseaseCancer (Past/Current)Seizure DisorderBleeding DisordersHemochromatosisDiabetesMigrainesChronic FatigueChronic Dehydration
Mental Health History:
Check all that apply.

AnxietyDepressionBipolar
If you clicked any of the above, how long have you been diagnosed?
Allergies
Medication:
Food:
Environmental:
Medications
Please list your current medications & supplements.
Lifestyle Factors
Smoking:

NeverTobaccoMarijuanaOther
Alcohol:

NeverRarelyModeratelyDaily
Recreational Drug Use:

YesNo
If "yes," what?
Pregnant/Breastfeeding:

YesNoN/A
Previous IV Therapy:

YesNo
Abnormal Labs (if known):

HypermagnesemiaHypercalcemiaHypokalemiaHemochromatosisLow B12Low Vitamin DKidney IssuesLiver Issues
Treatment Safety
Difficulty with IV Placement or fainting?

YesNo
Recent Surgery (past 3 months)?

YesNo
If "yes," what surgery?
Current infection or illness?

YesNo
Receiving chemotherapy or radiation?

YesNo
IV THERAPY CONSENT
This document serves as informed consent for Intravenous (IV) Infusion Therapy or Intramuscular Injection(s).
I have informed staff of allergies, medications, supplements, and full medical history.
IV Infusion Therapy has not been evaluated by the FDA and is not intended to diagnose, treat, cure, or prevent.
I understand I have the right to be informed of the procedure, alternatives, risks, and benefits before consenting.
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Risks

Please click to "initial" the form stating that you are aware.
Pain or Bruising
Infection
Phlebitis
Allergic Reaction
Dizziness or Fainting
Nausea
Electrolyte Imbalance
Fluid Overload
Acknowledgments

Please click to "initial" the form stating that you are aware.
I disclosed all medical history.
Alternatives were explained.
No outcomes are guaranteed.
I may refuse treatment at anytime.
Procedure and aftercare were explained.
Consent To Treat
I voluntarily consent to IV Vitamin & Hydration Therapy provided by Southtowns Colon Hydrotherapy, LLC dba.
Client Name

First NameLast Name
Date

MonthDayYear
Date
Client Signature

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Provider Name

First NameLast Name
Date

MonthDayYear
Date
Provider Signature

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Should be Empty:

SOUTHTOWNS COLON HYDROTHERAPY, LLC

IV VITAMIN & HYDRATION THERAPY

CLIENT INFORMATION

Conditions

Mental Health History:

Allergies

Medications

Lifestyle Factors

Treatment Safety

Risks

Acknowledgments

Consent To Treat