Vitalize IV Medical History & Consent Form


 


Name:  

D.O.B:  

Referred by?  

Emergency Contact (Name and Number):  

Allergies (Medication / Food Allergies / Vitamins:  

Current Medications (Must be Specific):  

Heart Condition

 

High Blood Pressure

 

  GI and Hepatic

 

Kidney Condition

 

Musculoskeletal

 

Endocrine

 

Lung Condition

 

Methylation Issues to your knowledge?

 

 

 


Medical Consent

This document is intended to serve as confirmation of informed consent for intravenous (IV) and Intramuscular (IM) therapy as overseen by the medical director at Vitalize IV.

I have informed the registered nurse of all current medications and supplements as well as any pre-existing medical conditions.
I have informed the registered nurse of any known drug allergies, or of any past reactions to anesthetics/intravenous therapy.
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits of IV therapy.

  • Benefits of intravenous therapy:

    • IV therapy is not affected by stomach or intestinal disease/malabsorption.

    • Full amount of IV infusion enters the bloodstream for availability to tissues.

    • Higher doses of nutrients can be given intravenously without intestinal irritation that can accompany doses given orally.

  • Risks and potential side effects of intravenous therapy:

    • Discomfort, bruising, and pain at the site of injection.

    • Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.

    • Severe reaction, anaphylaxis, cardiac arrest, or death.

  • Alternatives to IV vitamin therapy:

    • Oral supplementation

    • Dietary and lifestyle changes

I understand that I have the right to consent to or refuse any treatment at any time prior to its administration. My signature on this form affirms that I have given my consent to intravenous therapy and I am aware that other unforeseen complications can occur. Therefore, I give my consent to Vitalize IV using the Emergency Protocol should it be deemed necessary by the Registered Nurse or Paramedic. If the Emergency Protocol is not effective for the client, Vitalize IV RN’s reserve the right to call 911.

I understand that if I am currently, or was recently, under the influence of drugs and/or alcohol that Vitalize IV is not responsible for any adverse effects or interactions as a result of receiving IV Vitamin Therapy.
I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered by Vitalize IV medical staff. 

I understand that there is no implied or stated guarantee of success or effectiveness of any treatment offered at Vitalize IV. I understand that Vitalize IV is not treating or diagnosing any condition. I understand that I am free to withdraw my consent and to discontinue participation in treatment at any time. I understand that I will incur the full fee for treatment regardless of amount used.

My signature below confirms that:

  1. I understand the information provided above and agree to the foregoing.

  2. The procedure set forth above has been adequately explained to me by Vitalize IV Therapy nursing staff.

  3. I authorize and consent to the performance of the procedure.

Leave this empty:

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Signature Certificate
Document name: Vitalize IV Medical History & Consent Form
lock iconUnique Document ID: fca2fa51dd0c0dd414a0dd5bbf144d98770ff0bf
Timestamp Audit
September 18, 2020 12:43 pm CSTVitalize IV Medical History & Consent Form Uploaded by Stephanie Schofield - stephanie@vitalizeiv.com IP 47.222.6.216
September 18, 2020 3:37 pm CSTchris kilkenny - killedk@yahoo.com added by Stephanie Schofield - stephanie@vitalizeiv.com as a CC'd Recipient Ip: 47.222.6.216
September 18, 2020 3:45 pm CSTStephanie RN - stephanie@vitalizeiv.com added by Stephanie Schofield - stephanie@vitalizeiv.com as a CC'd Recipient Ip: 47.222.6.216
September 19, 2020 1:18 pm CSTStephanie RN - stephanie@vitalizeiv.com added by Stephanie Schofield - stephanie@vitalizeiv.com as a CC'd Recipient Ip: 47.222.6.216
September 19, 2020 1:25 pm CSTStephanie RN - stephanie@vitalizeiv.com added by Stephanie Schofield - stephanie@vitalizeiv.com as a CC'd Recipient Ip: 47.222.6.216
September 20, 2020 2:57 pm CSTStephanie RN - stephanie@vitalizeiv.com added by Stephanie Schofield - stephanie@vitalizeiv.com as a CC'd Recipient Ip: 47.222.6.216
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