IV INFUSION THERAPY — INFORMED CONSENT

IV INFUSION THERAPY — INFORMED CONSENT

CHI AESTHETICS & WELLNESS, LLCd/b/a Crystal Ngozi Beauty & Esthetics | 4135 LaVista Rd, Suite 200 | Tucker, GA 30084 | (404) 919-4984 | Medical Director: Nauman Rashid, MD
This form must be completed by the patient at each appointment.

Please complete this form before your session begins. All information is kept confidential.
PATIENT INFORMATION
Full Name:
Date of Birth:

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Date
Phone:
Format: (000) 000-0000.
Email:
example@example.com
ABOUT IV INFUSION: IV Infusion Therapy involves the administration of vitamins, minerals, antioxidants, and fluids directly into a vein via intravenous catheter. Sessions are administered by a licensed Registered Nurse under the supervision and Standing Orders of our Medical Director, Nauman Rashid, MD.
POTENTIAL RISKS
- By proceeding with IV Infusion Therapy, you acknowledge awareness of the following potential risks:
- Bruising, swelling, or discomfort at the insertion site
- Temporary redness or inflammation along the vein
- Mild nausea, dizziness, or lightheadedness during or after infusion
- Allergic reaction to one or more ingredients in the drip
- In rare cases: vein irritation (phlebitis), infiltration, or infection at the IV site
- Fluid overload in clients with certain kidney or heart conditions
- Rare but serious adverse reactions requiring emergency intervention

HEALTH DISCLOSURE — COMPLETE AT EVERY VISIT
The following conditions may prevent you from safely receiving IV Infusion Therapy. Please review this list carefully:
- G6PD Deficiency
- Kidney disease or reduced kidney function
- Congestive heart failure or fluid retention disorders
- Active infection, fever, or acute illness
- Pregnancy or suspected pregnancy
- Known allergy to any IV ingredient
- Current medications that may interact with IV nutrients
- Any other condition your provider should be aware of
PATIENT ACKNOWLEDGMENT
Medications, allergies, or anything else your RN should know:
PATIENT ACKNOWLEDGMENT
Date of Service:

MonthDayYear
Date
Patient Signature:
This form is required at every appointment and must be completed by the patient. Retain signed copy in patient file. Chi Aesthetics & Wellness, LLC | crystalngozibeauty.com | (404) 919-4984
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