SECTION A — PATIENT CONSENT
1. PURPOSE OF THERAPY
I voluntarily consent to receive intravenous (IV) hydration, vitamin, mineral, amino acid, electrolyte, medication additive, antiemetic, acid-reducer, anti-inflammatory, wellness, recovery, migraine, athletic, immune-support, illness-support, or provider-directed infusion therapy. I understand the treatment involves placement of a peripheral IV catheter into a vein for direct administration of fluids and approved additives.
Potential ingredients may include, when clinically appropriate:
● Normal saline
● Lactated Ringer’s
● Electrolytes
● Vitamin blends
● B-complex / B12
● Magnesium
● Vitamin C
● Amino acids
● Zofran (ondansetron)
● Pepcid (famotidine)
● Toradol (ketorolac)
● Benadryl (diphenhydramine)
● Other provider-approved additives
Final ingredients are determined solely by the provider.
2. WHO MAY QUALIFY
IV therapy may be considered only after provider assessment for:
● Mild to moderate dehydration
● Viral illness support
● Nausea / vomiting / diarrhea without ER red flags
● Migraine / headache support
● Heat exhaustion without instability
● Fatigue / wellness hydration
● Athletic recovery
● Travel dehydration
● Medication administration
● Electrolyte replacement
● Urgent care adjunctive treatment
● Other provider-approved outpatient indications
3. WHO SHOULD NOT RECEIVE IV THERAPY
I understand IV therapy may be unsafe and may be refused if I have any of the following:
● Congestive heart failure (CHF)
● Low ejection fraction / cardiomyopathy
● Kidney disease, dialysis, poor urine output, AKI, CKD stage 3+
● Liver failure / cirrhosis with ascites or edema
● Pulmonary edema
● Severe uncontrolled hypertension
● Active chest pain
● Shortness of breath at rest
● Oxygen saturation instability
● Suspected stroke / TIA symptoms
● Severe abdominal pain of unclear cause
● Active GI bleed
● Severe dehydration requiring ER level care
● Sepsis concern
● Altered mental status
● Pregnancy without provider approval
● Allergy to any fluid or additive
● Prior severe infusion reaction
● Active DVT or infected limb
● Severe electrolyte disorder
● Hypermagnesemia risk
● Unstable diabetes emergency
● Any condition requiring ER / hospital management
The provider may decline treatment at any time for safety reasons.
4. REQUIRED MEDICAL DISCLOSURE
I certify that I disclosed all relevant history including:
● Heart disease
● Kidney disease
● Liver disease
● Pregnancy / breastfeeding
● Current medications
● Blood thinners
● Diabetes
● Seizure disorder
● Hypertension
● Allergies
● Prior IV complications
● Reactions to Zofran, Pepcid, Toradol, Benadryl, magnesium, vitamins, or additives
I understand withholding information may significantly increase my risk.
5. RISKS & POSSIBLE COMPLICATIONS
I understand risks include:
● Pain, bruising, bleeding, redness
● Infiltration / extravasation
● Infection / cellulitis
● Phlebitis / thrombophlebitis
● Allergic reaction / anaphylaxis
● Vasovagal syncope
● Medication side effects
● Electrolyte imbalance
● Blood sugar changes
● Fluid overload
● CHF exacerbation
● Kidney injury worsening
● Shortness of breath
● Cardiac arrhythmia
● Compartment syndrome (rare)
● ER transfer
● Hospitalization
● Death (extremely rare)
6. NO GUARANTEE OF BENEFIT
No specific result is guaranteed, promised, or implied.
Benefits may include hydration, symptom improvement, nausea relief, migraine support, or recovery support, but outcomes vary.
7. LIMITS OF OUTPATIENT CARE / ER TRANSFER
This clinic does not replace emergency department care.
I understand treatment will be stopped and ER transfer / 911 may occur for:
● Chest pain
● Severe shortness of breath
● Stroke symptoms
● Severe allergic reaction
● Persistent hypotension
● Oxygen instability
● Severe abdominal pain
● GI bleed
● Altered mental status
● Sepsis concern
● Any provider-determined emergency
8. FINANCIAL RESPONSIBILITY
I understand IV therapy may be insurance-billed when medically necessary as part of an urgent care visit, or may be cash-pay depending on visit type. Prepared additives and administered medications are non-refundable.
9. CONSENT
I certify that:
● My medical history is accurate
● I understand risks, benefits, and alternatives
● I had the opportunity to ask questions
● The provider may refuse treatment
● I voluntarily consent to IV therapy