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Woodstock Location

103 Springfield Center Dr Ste 200

Woodstock, Ga, 30188

770-648-4828

I, hereby give consent to Hydration Institute to perform intravenous vitamin or mineral therapy or botulinum injections. I understand that intravenous nutrient therapy is not standard, widely approved or accepted for the purpose(s) of treatment of prevention of disease and the view that it is of benefit in the treatment of such disorders is accepted by a minority of the medical community and is considered "experimental" by most physicians. I am advised that other treatment approaches have been used in these conditions, including but not limited to prescription medications, over-the-counter drugs and nutritional supplements and these alternatives have been explained to my full satisfaction. I have informed the physician of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics. 

I have been informed of possible risks and side effects including but not limited to discomfort at the infection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowering of blood sugar levels, fever, and chills and generalized complaints. I understand that this therapy should not be used if I am pregnant unless I have sever life threatening disease. I understand the nature of the proposed therapy and the risks and dangers have been explained to me to my full satisfaction. If any conditions or allergies exist and not addressed at prior to infusion or injection, Hydration Institute employees or agents shall not be held liable.


While I understand that there have been no warranties or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations and materials that may be provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and the treatments to be utilized and all my questions have been answered to my full satisfaction. my signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof.



First Patients Name

First Name*

Middle Name

Last Name*

Phone*
First Patients Date of Birth*
First Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
First Patients Signature*
Second Patients Name

First Name*

Middle Name

Last Name*

Phone*
Second Patients Date of Birth*
Second Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Third Patients Name

First Name*

Middle Name

Last Name*

Phone*
Third Patients Date of Birth*
Third Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Fourth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Patients Date of Birth*
Fourth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Fifth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Patients Date of Birth*
Fifth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Sixth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Patients Date of Birth*
Sixth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Seventh Patients Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Patients Date of Birth*
Seventh Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Eighth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Patients Date of Birth*
Eighth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Ninth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Patients Date of Birth*
Ninth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Tenth Patients Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Patients Date of Birth*
Tenth Patients COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
Patients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Any known allergies to medication(s)*
No
Yes

Name of the medication(s)

If Yes, what reaction(s) occurs?
List your prescribed medications, vitamins, over the counter medications*

Click to customize text box label
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's COVID-19 Screening
Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea*
No
Yes
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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