Template Gallery

IV Therapy Infusion Consent and Waiver Please fill in your name Date of Birth Please fill in your phone number Please fill in your email Emergency Contact Allergy History Please list any allergies you may have Are you presently taking any medications? If so, please list below Medical History Do you have any cardiac issues? (arrhythmias, heart failure, heart valve surgery, etc.) Do you have any current or past history of deep vein thrombosis (DVT) or deep vein thrombophlebitis? Do you have any current or past history of pulmonary embolism? Do you have any current or past history of congestive heart failure? Do you have any current or past history of kidney disease, including kidney stones? Do you have any current or past history of liver disease? Do you have any current or past history of stroke, seizures, or neurological deficits? Do you have any current or past history of diabetes mellitus? Do you have any current or past history of bleeding disorders (i.e. hemophilia)? Do you have any current or past history of anemia (i.e., low red blood cell count)? Do you have any current or past history of high blood pressure? Do you have any current or past history of blood clots (i.e., venous thromboembolism)? Do you have any current or past history of cancer? If yes, please list type below Do you have any current or past history of metabolic disease (i.e., abnormal levels of electrolytes such as potassium, magnesium, or calcium)? Do you have any current or past history of hypervolemia (excess fluid volume)? Do you have any current or past history of hypernatremia (excess sodium in the blood)? Do you have any current or past history of hyperkalemia (excess potassium in the blood)? Do you have any current or past history of hypercalcemia (excess calcium in the blood)? Do you have any current or past history of hyperphosphatemia (excess phosphate in the blood)? Do you have any current or past history of hypermagnesemia (excess magnesium in the blood)? Do you have any current or past history of hyperosmolality (excess osmoles in the blood)? Do you have any current or past history of hypovolemia (decreased blood volume)? Do you have any current or past history of hyponatremia (low sodium in the blood)? Do you have any current or past history of hypokalemia (low potassium in the blood)? Do you have any current or past history of hypocalcemia (low calcium in the blood)? Do you have any current or past history of hypophosphatemia (low phosphate in the blood)? Do you have any current or past history of hypomagnesemia (low magnesium in the blood)? Do you have any current or past history of hypokalemia (high potassium in the blood)? Do you have any current or past history of hypersecretion of vasopressin (a hormone that helps to control the body's water balance)? Do you have any current or past history of dehydration or hypovolemia (low blood volume)? Do you have any current or past history of diabetes insipidus (a disorder characterized by large amounts of urine and extreme thirst)? Do you have any current or past history of adrenal insufficiency (a condition in which the adrenal glands do not produce enough hormones)? Do you have any current or past history of gout (a form of arthritis characterized by severe pain, redness, and tenderness in the joints)? Do you have any current or past history of a stroke? Do you have any current or past history of disease or injury to the brain or spinal cord? Do you have any current or past history of vertigo (a sensation of spinning or dizziness) or syncope (loss of consciousness) of known origin? Do you have any current or past history of myasthenia gravis (a neuromuscular disorder characterized by weakness and rapid fatigue of the voluntary muscles) or other neuromuscular disease? Do you have any current or past history of psychiatric disorder? Have you ever had blood or blood products transfused? If so, have you ever had a reaction? Have you ever had an adverse reaction to an intravenous (IV) or injectable medication? If so, please explain Do you have any current or past history of drug or alcohol abuse? Do you have any current or past history of any surgical procedures? If so, please explain Do you have any current or past history of any other medical conditions? If so, please explain Have you ever been pregnant or are you currently breastfeeding? Do you have any current or past history of any other medical conditions? If so, please explain Consent to Infusion Therapy. I hereby give XXX and/or his designees permission to perform the above procedures that have been described to me. The risks and benefits of the proposed therapy have been explained to my satisfaction. I understand that I have the right to refuse any procedure or medication.Voluntary Consent. I have had sufficient opportunity to read and understand the information provided in the consent form. I have had sufficient opportunity to ask questions and my questions have been answered to my satisfaction. I understand that I have the right to refuse consent. My decision to consent or refuse consent will not affect my right to future care or treatment. I consent to the procedure(s) described above.Costs and Payment. I understand that I am fully responsible for payment of all services rendered to me. I understand that my health insurance company may not pay for the procedure, even if I have provided my insurance information.Medications. I understand that medications given to me during infusion therapy may cause side effects, including, but not limited to:Fever - may occur after the infusion due to your body’s immune response to the medication.Infections - may occur due to your body’s immune response to the medication.Cardiac Effects - The infusion may affect your heart rate and blood pressure. Rapid changes can be dangerous.Fluid Overload - The infusion may cause an excessive amount of fluid in your body.Gastrointestinal Effects - The infusion may cause nausea, vomiting, diarrhea, or abdominal pain.Neurological Effects - The infusion may cause headaches, dizziness, or seizures.Respiratory Effects - The infusion may cause shortness of breath, respiratory failure, bronchospasm, or chest pain.Renal Effects - The infusion may cause kidney problems.Skin Effects - The infusion may cause rash, pruritus (itching), urticaria (hives), or flushing.Local Effects - The infusion may cause pain, swelling, redness, or irritation at the infusion site.Other - The infusion may cause other effects. I understand that any medical procedure has risks, which are listed above. I acknowledge that other risks and side effects may occur. I consent to the infusion therapy procedure and accept the risks and side effects associated with the procedure. I understand the risks and benefits of the proposed procedure and have no further questions.Voluntary Withdrawal of Consent. I understand that I may withdraw my consent at any time prior to or during the infusion. I understand that withdrawing my consent prior to or during the infusion may result in my health care provider being unable to provide the benefits of the infusion. I hereby provide informed consent for IV therapy infusion, which may include but is not limited to Myers cocktail, Glutathione, Vitamin C, Vitamin D, Vitamin B12, NAD+, MIC injections, and other injectable vitamins. I understand and acknowledge that the above infusions may have certain side effects, such as headache, upset stomach, or cold-like symptoms, and in rare cases, more serious side effects. I have been informed of the risks and benefits of IV therapy infusion, and I have had the opportunity to ask questions about the procedure and potential side effects. I certify that I have provided an accurate medical history and have disclosed all relevant medical information to my healthcare provider. I acknowledge that it is my responsibility to inform my healthcare provider of any changes to my medical history prior to my next scheduled IV therapy infusion. I understand that IV therapy infusion is not a substitute for a healthy lifestyle and does not guarantee a specific outcome. I acknowledge that individual results may vary. I understand that IV therapy infusion is a voluntary procedure and that I have the right to refuse or discontinue treatment at any time. I acknowledge that I have read and understand this informed consent form, and I hereby give my consent for IV therapy infusion. I hereby release and hold harmless Dr. Jose Enrique Chinchilla and his staff from any liability or responsibility for any adverse effects or complications that may occur as a result of my participation in IV therapy infusion. Please list any questions or concerns you have regarding IV therapy infusion: Please list any additional questions or comments you may have for the Provider Please fill date "I have read the above information and consent to this procedure." Patient/Guardian Signature