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iv-recovery Informed Consent Form

Date: November 21, 2024

iv-recovery Informed consent for hydration therapy services 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

Parent or Guardian's Email Address

Email*

Confirm Email*
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

First Name: *

Last Name: *

Birth Date: *

Phone Number (Digits Only): *

Address: *

City: *

State: *

Zip Code: *

Emergency Contact Name: *

Contact Relationship:

Contact Phone Number: *

Medical History


Current medications: (please include all prescription medications and over the counter medications): *

Allergies and Type of Reaction:
Have you been hospitalized or under medical care in the past month?*
Yes
No
Congestive Heart Failure?*
No
Yes
Liver Disease?*
No
Yes
Kidney Disease or Renal Insufficiency?*
No
Yes
Gastrointestinal bleeding?*
No
Yes
Do you currently take a blood thinner?*
No
Yes
Do you currently take or use any type of steroid?*
No
Yes
Are you pregnant?*
No
Yes
Please be aware if you answered yes to any of the above, you may not be a candidate to receive IV Fluids. Check this box to agree. *
Agree
I understand that IV hydration and vitamin administration services provided by iv-recovery carries risk. *
Agree
I acknowledge I am responsible for any medical care I have that is directly or indirectly related to the services provided by iv-recovery. *
Agree
If I seek medical treatment for any side effect or reaction, it is at my own expense. *
Agree
I acknowledge that iv-recovery relies upon information provided by me in assessing my ability to participate in services provided. This includes that I have never been diagnosed or treated for any illnesses or conditions that may result in increased risk when participating in iv-recovery services. I understand that iv-recovery will not screen for, diagnose, monitor, or provide any care for such conditions or illnesses. *
Agree

I am aware that the following are risks of IV hydration:

  • - Inflammation/swelling
  • - Bruising or scarring from IV infiltration
  • - Misplacement of IV lines
  • - Adverse interactions with medications
  • - Lightheadedness or fainting
  • - Infection
  • - Bleeding
  • - Allergic Reaction
  • - Fluid Overload


Please agree to the above statement: *
Agree
I acknowledge that I have been given the opportunity to discuss possible risks and complications associated with IV hydration services. *
Agree
I waive any and all claims related to the services provided and agree to hold iv-recovery harmless regarding any complications or consequences I experience during or following the experience. *
Agree

By signing this document I confirm that:

  • I have read, understand, and agree to the above statements. 
  • I am 21 years or older and capable of making sound decisions. 

This document serves as an informed consent for IV hydration therapy from iv-recovery,

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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