Intravenous (IV) Therapy Consent Form

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Patient Information

First Name*

Last Name*

Email Address*

Date of Birth*

Address*

City*

State*

Zip Code*

Select your IV Treatment*

Phone Number

Race*

Driver’s License Number*

Drivers' License State*

Patient Vitals

Biological Sex*

Height (inches)*

Weight (lbs)*

Who is your Primary Care Provider?*

Blood Pressure (Systolic)*

Blood Pressure (Diastolic)*

Last Bloodwork/Labs*

Last Physical Exam*

Health History

Please list all medications, supplements, or current hormone dosages & frequencies of what you are currently taking*

Are you currently on or have you taken in the past hormone replacement?*

Yes

Please Specify Type of Hormone Replacement*

Personal Health History - Please check all that apply*

Family History - Does anyone in your family (living or deceased) have the following*

Do you Smoke?*

Yes

Do you Drink Alcohol?*

Yes

Do you use any Illicit Drugs?*

Yes

Are you sexually active?*

Yes

Smoking Type and Frequency*

Alcohol Type & Frequency*

Drug Type & Frequency*

Do You Desire More Children*

Yes

Are you pregnant or trying to get pregnant?*

Yes

Last Pap smear & any abnormal results

If not trying for a pregnancy list contraceptive or barrier method you are using

Number of pregnancies and live births

Last Mammogram, any abnormal results?

Symptoms - Are you noticing:*

Please list any allergies

Disclosures

I consent to the insertion of a peripheral intravenous catheter and to the infusion of fluids, vitamins, mineral and/or compounded cofactor, and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion. Further, I acknowledge that statements regarding vitamin and mineral infusions have not been evaluated by the FDA and that the infusion of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition. I understand that the infusion is being carried out under the direction of Monelle Burrus FNP-c and by a nonphysician who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous catheters and infusions. If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued. I have informed the nurse and/or provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or provider of my medical history. 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 to give my informed consent. I understand that: The procedure involves inserting a needle into a vein and injecting the prescribed solution. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. Risks of intravenous therapy include but not limited to: Occasionally: Discomfort, bruising and pain at the site of injection. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death. I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or providers(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or providers(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.*

I have read, understand, and consent to the above

I understand that the infusion is being carried out under the direction of Monelle Burrus FNP-c and by a nonphysician who is trained in the safe insertion, monitoring, stabilization, and removal of intravenous catheters and infusions. If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued.

I have informed the nurse and/or provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or provider of my medical history.

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 to give my informed consent.

I understand that:

The procedure involves inserting a needle into a vein and injecting the prescribed solution.

Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.

Risks of intravenous therapy include but not limited to:
1. Occasionally: Discomfort, bruising and pain at the site of injection.
2. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
3. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or providers(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or providers(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

HIPAA Consent*

I have read, understand, and consent to the above

Your right to privacy in this medical practice is paramount and we will never disclose any of your personal information without your express consent, unless required to do so by law. This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. Please read it carefully. The Physician will acquire private information about their patients. This is confidential and will not be discussed outside the office, except that the Physician may discuss patients with other healthcare professionals in terms that do not allow identification of the individual. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts, or contact by alternative means. Additionally, we may be required to disclose your health information in the following circumstances: In the event of an emergency; if required by law; if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care; if ordered by the courts, government authorities, public health, law enforcement, coroners, or funeral directors; in the event of organ donations, research, military activity, or for national security.

Patient Name:*

Signature*

Date*

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