Intake Consent Form

Fill out the form below and we will get back to you as soon as possible.

Client’s First and Last Name:

Phone Number

Gender

Client’s Date of Birth:

Client’s Information:

Height:

Weight:

BMI:

Allergies:

Medication

Are you experiencing any shortness of breath?

Have you recently or are you currently experiencing any bleeding?

Have you recently or are currently experiencing chest pain?

Have you recently or are you currently experiencing any edema or swelling?

Do you have any of the following conditions:

End Stage Renal Disease

Cardiac Arrhythmias

G6PD Deficiency

Kidney/Renal Disease

Low blood pressure

Are you taking or have you been told you need to take Digoxin?

Have you been told you have a decreased GFR or kidney problem?

** If you have any of the conditions mentioned above you may not be medically approved for IV hydration therapy. Your nurse will discuss this with you before continuing.

Do you have any medical concerns today?

If yes, what are the concerns

Could you be pregnant?

Are you breastfeeding?

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Email Address:

Confirm Email:

Emergency Contact Information:

Emergency Contact’s Name:

Emergency contact’s phone number:

Infused Vitality Health and Wellness reserves the right to refuse to initiate or continue any IV therapy treatment at any time based on the RN or staff’s discretion. By signing below, I hereby agree that all of the above information is true and accurate to the best of my knowledge.

Signature

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