IV Therapy Intake & Consent Form

This form is intended to provide you with an overview of your treatment today, to explain the risks and possible side effects of such treatment, to collect a medical history from you to ensure that today’s treatment is appropriate, and obtain your consent for today’s treatment. Please read through this form in its entirety and complete it to the best of your knowledge prior to receiving any treatment. If you have any questions regarding the information in this form, please consult your infusion nurse or physician prior to receiving today’s treatment.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

FemaleMale

Are you over the age of 18?

YesNo

Emergency Contact Name:

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Consent Checkboxes*

Do you currently have or previously have a history of any of the following (choose yes or no):

Diabetes

YesNo

High Blood Pressure

YesNo

Hepatitis

YesNo

Cancer

YesNo

Thyroid Imbalance

YesNo

Hormone Imbalance

YesNo

HIV/AIDS

YesNo

Seizure Disorders

YesNo

Stroke

YesNo

Allergies/Asthma

YesNo

Sickle Cell Anemia

YesNo

Kidney Problems

YesNo

Heart Disease/Heart Attack

YesNo

Lower Extremity Swelling/Edema

YesNo

Bleeding Disorders

YesNo

Leber's Disease

YesNo

G6PD Deficiency

YesNo

Liver Disease

YesNo

Current Infection

YesNo

Electrolyte Imbalance

YesNo

Vitamin Deficiency

YesNo

Abnormal Bloodwork

YesNo

Hypermagnesemia (high magnesium)

YesNo

Hypercalcemia (high calcium)

YesNo

Hypokalemia (low potassium)

YesNo

Hemochromatosis (high iron)

YesNo

If you answered yes to any of the above, please describe

Please list all medications (prescription, over the counter, vitamins, herbs, and supplements) you are currently using:

Rows	Medication/Supplement Name	Date Started	Dosage
1
2
3
4
5
6
7

Please list any allergies you have to medication, food, materials, or metals:

Please list any prior surgeries or hospitalizations you have had and the dates:

Medication / Supplement History

Please answer the following questions

Are you currently pregnant or breastfeeding?

YesNo

Do you smoke?

YesNo

If yes, how often?

Do you drink alcohol?

YesNo

If yes, how many drinks per week?

Do you use recreational drugs?

YesNo

If yes, which ones and how often?

Please describe any other health history or concerns that you have that have not been addressed above:

Intravenous (“IV”) therapy is the administration of fluids, medications, vitamins, and/or minerals directly into the bloodstream. This is done by inserting a needle or cannula into a vein (typically in the forearm, wrist, back of the hand, or top of the foot).

Your body normally absorbs nutrients slowly over the course of time. However, IV therapy allows your body to rapidly absorb nutrients at higher doses. This can lead to quick hydration and replenishment of vital nutrients, making it particularly beneficial for individuals seeking immediate relief from dehydration, fatigue, or nutrient deficiencies. Moreover, elective IV therapy can be customized to individual needs, allowing for tailored solutions to support overall wellness, boost energy levels, and enhance recovery after strenuous activities or illness. The infusion procedure typically takes 30 to 45 minutes.

Prior to your treatment, a nurse will discuss your health goals and your medical history with you. If you have any serious medical conditions, then you may be required to provide recent bloodwork, physician clearance, or further testing prior to receiving IV treatment.

IV therapy and any claims made about IV 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 therapy is not a substitute for your physician’s medicalcare.

Potential risks of IV therapy may include, but are not limited to: mild to moderate discomfort, pain, bruising at injection site, infection at injection site, damage to blood vessels, swelling at or around injection site, inflammation of veins, dizziness or fainting, changes in blood pressure or blood sugar during or after treatment, fluid overload, electrolyte imbalance, bleeding, allergic reaction, skin necrosis, warming or burning sensation at the site of injection, thrombophlebitis or venous thrombosis, air embolism, general malaise or fatigue post treatment, fever, nausea, and in extremely rare cases, anaphylaxis, cardiac arrest, or death.

You should not have elective IV therapy done if you:

- Have severe dehydration requiring immediate medical attention.
- Are allergic to components commonly used in IV solutions (*please let your
nurse know of any allergies you have prior to the procedure)
- Have any medical condition that may be made worse by IV therapy, including
without limitation, congestive heart failure, severe kidney disease, or electrolyte
imbalances
- Have a known blood clotting disorder or a history of thrombosis
- Have untreated or uncontrolled hypertension (high blood pressure)
- Have heart failure or severe cardiac disease
- Have liver disease or liver failure
- Are pregnant or breastfeeding
- Have an active infection
- Have undergone recent surgery or trauma involving the veins or circulatory
system
- Have any other significant medical condition

It's important for individuals with these contraindications to consult with their healthcare provider before undergoing IV therapy to ensure safe and appropriate treatment options.

Elective IV therapy is a strictly voluntary treatment. The treatment is not necessary or required. The alternative forms of treatment include not undergoing the IV infusion procedure, oral supplementation and/or dietary and lifestyle changes.

After your treatment is complete you should:
1. Apply pressure to the site for at least two minutes after the IV is removed.
2. Keep the bandage in place for at least one hour.
3. You may use warm packs and elevate your arm to reduce discomfort and promote healing.
4. You may use cold packs for pain relief and to reduce swelling.
5. Stay hydrated by continuing to drink water.
6. Contact us or your primary care physician if you experience any concerning
symptoms or if certain symptoms worsen post-treatment, including significant
swelling, increasing redness over the vein, persistent vein/arm pain, or headaches
that are unresponsive to hydration or over-the-counter pain relievers.
7. If you experience life-threatening symptoms or an emergency, call 911 immediately.

Elective IV therapy offers a range of potential results. One primary outcome is enhanced hydration, which allows for increased energy, mental clarity, and overall feeling of wellbeing. IV therapy also delivers essential vitamins, minerals, and antioxidants directly into the bloodstream, which promotes optimal nutrient levels in order to support various bodily functions. This infusion of nutrients can result in increased energy levels, improved mood, and enhanced cognitive function. IV therapy may also help with detoxification by flushing out toxins and waste products from the body and contributing to a revitalized feeling.

Most patients feel better immediately after treatment. However, some patients may
temporarily feel tired or unwell due to the detoxification process.

It is important to note that while many individuals experience positive effects from IV therapy, results are not guaranteed and can vary depending on factors such as lifestyle,diet, and overall health status. For some people, achieving desired outcomes may require multiple treatments to sustain the benefits over time. Therefore, regular sessions of IV therapy may be recommended as part of a holistic approach to health and wellness maintenance. Consulting with a healthcare provider can help determine the most suitable treatment plan to optimize results based on individual needs and goals.

Elective IV therapy procedures require payment at the time of service. They are not reimbursable by government or private healthcare insurance providers.

All services provided by East Lake IV Lounge are elective wellness treatments and are paid in full at the time of service. By proceeding with services, you acknowledge and agree to the following:

All sales are final. No refunds will be issued for any services rendered, including IV therapy, injections, or add-ons.
Once an IV has been started or an injection has been administered, the service is considered fully performed and non-refundable, regardless of outcome or personal expectations.
If a service is discontinued due to discomfort, vein access issues, or patient request, no partial or full refunds will be provided.
Prices are clearly listed and agreed upon prior to treatment, and no adjustments will be made after services are rendered.
East Lake IV Lounge does not bill insurance. All services are considered self-pay.
In the event of a pricing or payment processing error, corrections will be made at the discretion of East Lake IV Lounge.
Chargebacks or payment disputes are not permitted for services that have been rendered and agreed upon. By signing below, you agree to contact East Lake IV Lounge directly to resolve any concerns.
By signing, you confirm that you understand and agree to this financial policy.

Please initial under each statement

I consent and authorize the administration of IV infusion therapy on me.

I have received, reviewed, and understand this Intake and Consent Form and have had the opportunity to ask questions

I have informed the nurse or physician of any known allergies to medications or other substances.

I acknowledge I have been provided the Notice of Privacy Practices

I understand the risks and potential complications associated with IV therapy procedures and understand that results cannot be guaranteed.

I understand that IV therapy is an elective procedure and alternative treatment options have been explained to me.

I have been provided with and understand the aftercare instructions and am aware that not following the instructions can lead to unsatisfactory results and potential complications.

If I experience pain or discomfort during the procedure, I will immediately inform the nurse or physician.

I understand that the nurse or physician reserves the right to refuse to perform treatments on anyone whom s/he deems to have a condition for which IV therapy is contraindicated.

I am over the age of 18.

I am not under the influence of alcohol or drugs.

I am not currently pregnant or breastfeeding.

I First Name Last Name , certify that the information provided by me in this form is accurate and correct to the best of my knowledge. I have read and understand this form in its entirety. I voluntarily consent to today's treatment.

Signature

Date

We may take photographs and/or videos of you to document today’s treatment. You may choose whether you want to allow us to share the photographs and/or videos for advertising, educational, and marketing purposes by initialing below (please initial):

Patient does not agree to the photo release. We will keepyour images private and will not share with anyone.

No

Patient agrees to the following photo release:Patient assigns the IV Clinic the right to use and publishphotographs and/or videos of the Patient and permission touse the Patient’s image or likeness in any and all forms ofmedia for commercial purposes, advertising, trade, personaluse, educational, and any other purpose or in any othermanner and medium, to alter the same without restriction,and to copyright the same without restriction. The Patientreleases all claims to profits that may arise from use of suchimages. The Patient agrees that the IV Clinic may use Patient’slikeness and images on the IV Clinic’s website or otheradvertising or social media.

Yes

Name

First NameLast Name

Signature

Date

I First Name Last Name , voluntarily and fully assume all risks, regardless of severity, that I may sustain in connection or associated with the today’s elective IV therapy treatment. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the IV Clinic and their successors, assigns, employees, contractors, officers, directors, agents, affiliates, subsidiaries, and parent company, each and all of them (collectively, the "Releasees"), on account of personal injury or property damage arising out of or relating to today’s elective IV therapy treatment. I will not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from any and all liability under such claims. All matters arising out of or relating to this waiver and release will be governed by and construed in accordance with the laws of the State of the IV Clinic’s address as listed on page 1 of this Intake and Consent Form (the “State”), without giving effect to any choice or conflict of law provision or rule. Any claim or cause of action arising under this waiver and release may be brought only in the federal and state courts located in the city and State of the Practice’s address as listed on page 1 of this form, and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the remainder will continue in full legal force and effect. I further agree that if this waiver and release is not valid as such in the State, then it will be construed as a covenant not to sue.

I acknowledge that at the time of signing this form, I am of sound mind and capable of making independent decisions for myself.

I HAVE READ THIS WAIVER AND RELEASE AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS WAIVER AND RELEASE VOLUNTARILY.

Signature

Name

First NameLast Name

Date

IV Therapy Intake & Consent Form

Patient Information

About the Procedure

Potential Risks

Contraindications

Alternative Treatments

Post Treatment

Results

Cost

Informed Consent

Photo/Video Consent

Waiver and Release of Liability