Medical Questionnaire For Nutrient IV Therapy: In order for us to serve you better. Please answer the following: Check Yes or No: If yes to any question, please explain. Have you now or had in the past?
1. Congestive Heart Failure?
2. Severe Renal Impairment?
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3. Heart Attack / Stroke?
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4. Condition of Sodium Retention or Electrolyte Imbalance?
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5. Edema Water Retention?
6. High / Low Blood Pressure?
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7. Severe Frequent Headaches?
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8. Fainting / Seizures / Epilepsy?
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9. Diabetes / Low Blood Sugar?
10. Any liver conditions? (e.g. Liver Cirrhosis, Liver Disease)
11. Any allergies? If yes, please list below (allergies section)
12. Do you have Sulfa Allergies?
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13. Do you have or have had asthma?
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14. What is your medical history? Please list below (allergies section)
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15. *Females Only: Are You Pregnant?
Terms, Conditions & Consent for IV Hydration Therapy
Our hydration therapy is specifically designed to counteract symptoms of dehydration, fatigue, and the residual effects of nutrients and H2O depletion. We offer no diagnostic testing, make no medical diagnoses, and reserve the right to refuse treatment to any patients we deem are intoxicated unstable, or whose symptoms are not consistent with the above. The vast majority of our clients receiving our therapy feel greatly improved; however, every individual is different and there is no guarantee that you will feel better after an infusion; nor does your improvement of symptoms exclude other coexisting potential medical conditions. This document is designed to serve as confirmation of informed consent for IV therapy as suggested by the qualified staff present at the current location.
I have informed the staff of any known allergies to drugs or other substances, or of any past reactions to anesthetics. I have informed the staff of all current medications and supplements I am taking.
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and give my concerns.
I understand that
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The procedure involves inserting a needle into a vein and injecting the selected solution.
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Risks of intravenous therapy include, but are not limited to: discomfort, bruising, and pain at the site of injection.
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Other rare but possible side effects include but are not limited to: inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
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Nutrients are forced into the cells by means of a high concentration ingredient.
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I understand the information provided on this form and agree to the foregoing.
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I have received all the information and explanation I desire concerning the procedure.
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I authorize and consent to the performance of the procedures(s).
