IV VITAMIN THERAPY CONSENT FORM
(WELLNESS TREATMENT)
Patient Name:
Date of Birth:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address:
Phone Number:
Format: 00000000000.
Email:
example@example.com
1. PURPOSE OF TREATMENT
IV Vitamin Therapy involves the intravenous administration of fluids, vitamins, minerals, and/or amino acids to support general wellness, hydration, and nutritional balance. This treatment is not intended to diagnose, treat, cure, or prevent any disease and is considered a complementary wellness therapy.
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2. PROCEDURE
The procedure involves inserting a needle into a vein to deliver a customized IV infusion. The treatment typically lasts between 30–60 minutes.
3. POTENTIAL BENEFITS
Possible benefits may include:
Improved hydration
Increased energy levels
Enhanced immune support
Improved skin appearance
Recovery support after illness, travel, or exercise
Results may vary and are not guaranteed.
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4. RISKS AND SIDE EFFECTS
While generally safe, IV therapy carries potential risks, including but not limited to:
Discomfort, bruising, or infection at the injection site
Vein inflammation (phlebitis)
Allergic reactions
Dizziness or fainting
Fluid overload (rare)
I understand that unforeseen complications may occur.
5. MEDICAL DISCLOSURE
I confirm that I have disclosed all relevant medical history, including:
Medical conditions (e.g., kidney disease, heart disease, diabetes)
Allergies (medications, vitamins, etc.)
Current medications or supplements
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• Pregnancy or breastfeeding status
6. CONTRAINDICATIONS
I understand IV therapy may not be suitable for individuals with certain conditions, including but not limited to:
• Kidney disease
• Congestive heart failure
• Certain electrolyte imbalances
7. VOLUNTARY CONSENT
I understand:
• This is an elective wellness treatment
• I may withdraw consent at any time
• No guarantees have been made regarding results
I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.
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8. LIABILITY WAIVER
I release and hold harmless the practitioner and clinic from any liability associated with this treatment, except in cases of negligence.
9. PRIVACY
My personal and medical information will be kept confidential in accordance with applicable data protection laws.
10. CONSENT
I, , hereby consent to receive IV Vitamin Therapy.
Patient Signature:
Date:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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EMERGENCY CONTACT
Name:
Relationship:
Phone Number:
Format: 00000000000.
Please tick if any of this applies to you.
G6PD deficiency
Chronic kidney disease (CKD) or kidney failure
History of kidney stones (especially calcium oxalate stones)
Hemochromatosis (iron overload)
Thalassemia with iron overload
Congestive heart failure (CHF)
Severe liver disease
Diabetes mellitus
Asthma (especially poorly controlled asthma)
Active cancer (requires oncologist approval)
Pregnancy or breastfeeding (use only under medical supervision)
Previous allergic reaction to IV glutathione or vitamin c
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