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IV/IM Infusion Consent



The below client as a recipient hereby consents to the administration of intravenous infusion (IV infusion) and/or intramuscular injection (IM injection) including vitamins, minerals, and other nutrients. 



I understand that complications include but are not limited to:

  • Burning and/or swelling at the infusion site
  • Fainting or lightheadedness
  • Allergic reaction
  • Bruising or hematoma at injection site
  • Localized thrombophlebitis
  • Fatigue



I understand that I must disclose any and all medical conditions and all medications either prescribed by a provider or those I am taking over the counter. 



I understand that the specific IV infusion or IM injection I am receiving are not intended or will not treat or diagnose any current or past medical condition and that I should consult with my primary or specialty care physician prior to receiving an IV infusion or IM injection. 

I understand that I can elect to stop the IV infusion or IM injection at anytime.

I understand that I must contact my primary or specialty provider prior to or for follow-up care prior to the infusion for any care related to a current or past medical condition. 

I understand the risks of complications related to the IV infusion and/or IM injection and all questions or concerns have been answered and understood. 

I understand that the services provided may not be medically necessary and/or not indicated and have not be subject to peer reviewed scientific testing. 

I understand and agree to all services rendered are charged directly to me and I am personally responsible for the payment. I understand that services rendered will not be forwarded to any insurer or payor and that I will not forward costs to any insurer or payor. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with the associated risks. I hereby give consent to perform this and all subsequent intravenous infusion (IV infusion) or intramuscular injection (IM injection) treatments with the above understood. I hereby release the nurse or doctor preforming the IV infusion or IM injection and the facility from liability associated with this procedure.







                  July 5, 2024








First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name *

Emergency Contact's Phone Number *

Name of Nurse or Provider administering infusion *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Health History

All questions answered will remain strictly confidential and will remain apart of your medical records. This Self-reported health history is good for 12 months, unless a change in your medical history should occur. You should then fill out a new self-reported health history.
Please select all that apply to your current or past medical history.
Heart Disease
Stroke/TIA
Bleeding Disorder
Diabetes (Type 1 or Type 2)
High Blood Pressure
Irregular heart rate or rhythm
Peripheral Edema
Kidney disease or dysfunction
Dialysis
GI Disorder
Stomach Ulcers
Syncope or passing out
Lymphedema
Cancer (current or past history)
Currently Pregnant or Breastfeeding

If yes to any of the above, please explain.

Other Health conditions not listed above?

Allergies? (Type/Reaction)

List all prescription and over-the-counter medications.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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