INTRAVENOUS (IV) INFUSION THERAPY INTAKE FORM
Patient Information (Please use full legal name)
Name
First Name
Last Name
Date of Birth (MM/DD/YYYY)
-
Month
-
Day
Year
Date
Age
Sex
Male
Female
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Occupation
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
How did you hear about us?
Internet
Facebook
Instagram
Referral
What are your main concerns? (Check all that apply)
Fatigue/ Low Energy
Allergies
Cold or Flulike Symptoms
Difficulty Concentrating
Recent Surgery
Recent Illness
Changes in Mood
Stress
Headaches/ Migraines
Malabsorption Issues
Dry Skin
Facial Wrinkles/ Fine Lines
Difficulty Losing Weight
Other
Medical History
Are you Pregnant or Breastfeeding?
Yes
No
Are you a Smoker?
Yes
No
Are you a Diabetic?
Yes
No
Are you ALLERGIC to any Medications or Food?
Yes
No
Do you take Digoxin (Lanoxin)?
Yes
No
Do you take Diuretics or Water Pills?
Yes
No
Do you take Prednisone or Steroids?
Yes
No
Do you use any Recreational Drugs?
Yes
No
How many Alcoholic Drinks do you consume in a week?
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Medical History (Continued)
Have you ever had an Electrolyte Imbalance? (Check all that apply)
Hemochromatosis (High Iron Levels)
Hypercalcemia (High Calcium Levels)
Hypokalemia (Low Potassium Levels)
Hypermagnesium (High Magnesium Levels)
Other
Do you have any of the following Medical Conditions?
Hypertension (High Blood Pressure)
Hypotension (Low Blood Pressure)
Cardiovascular Disease
Kidney Disease
Asthma
Sarcoidosis
Stroke/ TIA
G6PD Deficiency
Sickle Cell Anemia
Optic Nerve Atrophy
Hyperthyroidism
Hypothyroidism
List ALL Medical Conditions (Not Mentioned Above)
List ALL Medications (Prescription & Over-the-Counter)
List ALL Past Surgeries (Include Dates)
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INTRAVENOUS (IV) INFUSION CONSENT TO TREAT
I hereby give my consent to my Medical Provider at S&K Primary Care, LLC, and his/her designated healthcare provider for the administration of IV Hydration.
Initials
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits of IV Hydration Therapy. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and given my informed consent. I have the right to refuse any treatment prior to its administration.
Initials
IV Hydration Therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. IV Hydration Therapy is not a substitute for medical care.
Initials
I have informed the nurse and/ or Medical Provider of any known allergies to medications or other substances, and all current medications and supplements. I have fully informed the nurse and/ or Medical Provider of my medical history.
Initials
I understand that:
The procedure involves inserting a needle into a vein and injecting the prescribed solution.
Alternatives to IV Hydration Therapy are Oral Supplements and/ or Dietary and Lifestyle Changes.
Risks of IV Hydration Therapy include but are not limited to:
Occasionally: Discomfort, bruising and pain at the site of injection.
Rarely: Inflammation of the vein used for the injection, phlebitis, metabolic disturbances, and injury.
Extremely Rare: Severe allergic reaction, anaphylaxis, cardiac arrest and death.
Benefits of IV Hydration Therapy include:
Nutrients are absorbed into the cells by means of a high concentration gradient.
Higher doses of nutrients can be given without intestinal irritation.
Initials
I do not expect the nurse and/ or Medical Provider to anticipate risk and complications. I trust that the nurse and/ or Medical Provider will exercise judgement during the course of treatment with regards to my procedure.
Patient Full Name
Patient Signature
Date
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Month
-
Day
Year
Date
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HIPAA COMPLIANCE CONSENT FORM
The notice of Privacy Practices provides information on how we use or disclose protected health information.
This notice describes your rights under the law. By signing this agreement, you acknowledge that you have reviewed the notice before signing your consent.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), allows for the use of information for treatment, payment or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in publications. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The Practice has the right to change the Privacy Police as allowed by law.
The Practice has the right to restrict the use of information, but the Practice does not have to agree to those restrictions.
I have the right to revoke this consent in writing at any time, and all full disclosures will then cease.
The Practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send a text to you to confirm your appointments?
YES
NO
May we leave a message on your answering machine at home or on your cell phone?
YES
NO
May we discuss your medical condition with any member of your family?
YES
NO
If YES, please name the members allowed:
Patient Full Name
First Name
Last Name
Patient Signature
Date:
-
Month
-
Day
Year
Date
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