Vitalize IV Medical History & Consent Form
Emergency Contact (Name and Number):
Allergies (Medication / Food Allergies / Vitamins:
Current Medications (Must be Specific):
Heart Condition YesNo
High Blood Pressure YesNo
GI and Hepatic YesNo
Kidney Condition YesNo
Lung Condition YesNo
Methylation Issues to your knowledge? YesNo
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:
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:
I understand the information provided above and agree to the foregoing.
The procedure set forth above has been adequately explained to me by Vitalize IV Therapy nursing staff.
I authorize and consent to the performance of the procedure.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Vitalize IV Medical History & Consent Form
Agree & Sign