IV Infusion Intake & Consent Form

IV Infusion Intake & Consent Form

Please complete this form before your IV infusion session. Your information will remain confidential.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any allergies?
If yes, please list your allergies
Are you currently taking any medications?
If yes, please list your medications
Do you have any of the following medical conditions?

Other (please specify below)
Please specify any other medical conditions
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HIPAA Release Form
Consent
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
I agree
This Release of information will remain in effect until terminated by me in writing
Which number should we call?

Other
Other Means of Contact
If unable to reach me
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Informed Consent

Please review the following information before continuing.
By continuing, you confirm that you understand the information provided and agree to proceed with the treatment as explained.
To the Patient
We would like you to have the following information so that you can make an informed decision regarding IV hydration therapy.
What is Intravenous Therapy
IV re-hydration/nutritional therapy is a treatment that involves injecting fluids into the vein that vitamins, minerals, amino acids and other nutrients are slowly administered via a small needle into the client's vein.
Benefits Included
When nutrients are administered by IV, absorption is achieved at higher and safe concentrations. This allows circulation to be easily obtained by your cells so your body can heal, repair, function and maintain optimal health.
Treatment
The area into which the IV catheter needle will be inserted is disinfected. The qualified individual then inserts the needle into a vein in the arm and secures the needle in place to the skin. The insertion of the needle feels like a mild sting, but the pain quickly goes away. The amount of fluid entering the vein may be regulated by a manual dial attached to the tubing. A qualified individual will assess the site time to time to verify the rate of fluids is correct and that the site is not leaking or moving. The length of time for treatment depends on the severity of the dehydration and proposed treatment. We do not diagnose, treat, or cure any specific disease. The purpose of treatment will be: improve over all nutritional status, improve general sense of well-being, improve metabolism, slow down the aging process.
Risk and Complications
Risks associated with IV re-hydration are low for most adults. There is a risk of infection occurring at the site of the needle. In most cases, such infections can be treated easily. Another possible risk is creating an imbalance of nutrients in your body if the fluid solution contains the wrong mix of electrolytes. Caregivers should be monitoring to determine if an imbalance or deficiency occurs.

The needle at the insertion site may become dislodged which can cause infiltration. This means that the fluid goes into the tissues around the vein. This may cause a burning or stinging sensation at the site and a bruise. The needle can be removed and reinserted into a different vein. A warm compress can be used to reduce swelling. Keeping still during re-hydration can prevent dislodging.

Other rare adverse effects from IV therapy include but are not limited to: Allergic reactions to a nutrient, needle, or other supplies used, fever, nausea, upset stomach, and malaise due to changes in blood pressure, and any unforeseen adverse effects.
I understand that this treatment is strictly voluntary. Therefore, NO SPECIFIC PROMISES OR GUARANTEES OF RESULTS CAN BE MADE for any degree or improvement of my particular condition. There can be NO REFUNDS given for any treatment rendered, regardless of results. I understand that the benefits of IV therapy are much greater if I follow a healthy lifestyle ( non-smoking, weight control, proper exercise, diet and nutritional supplementation.)
I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS ENTIRE DOCUMENT AND IT HAS BEEN FULLY EXPLAINED TO ME. I HAVE BEEN GIVEN AN OPPORTUNITY TO ASK QUESTIONS AND THEY HAVE BEEN ANSWERED TO MY SATISFACTION.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

IV Infusion Intake & Consent Form

HIPAA Release Form

Informed Consent

To the Patient

What is Intravenous Therapy

Treatment

Risk and Complications