IV Consent

Patient Information

Name*

First Last

Date*

Birth Date*

Gender*

Male
Female

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you pregnant? If yes, how many weeks?*

Contact Information

Name

First Last

Phone

Waiver of Liability and Informed Consent Release

I hereby request and consent to the performance of IV injections .

Name of vitamin injected (if applicable)

I consent to the treatments and other procedures within the scope of the practice of _________________________employed by Ideal Body Clinic on me (or on the patient named above, for whom I am Legally responsible).

name of physician*

I have been informed that IV injection is generally considered to be a safe method of treatment, but it may have some side effects, including muscle pain, headaches, and change of blood pressure and weakness that may last for a few days. An infection is another possible risk, although we use only sterile disposable needles and maintain a clean and safe environment. I understand that while this document describes the major risks of treatment other side effects and risks may occur. I also understand that IV treatment is not a substitute to the treatment recommended by my doctor. My prescribed treatments should be continued along with IV injections

Initials*

I understand the clinical and administrative staff may review my patient records, but all my records will be kept confidential and will not be released without my written consent. I affirm that I have provided information about my health that is true and correct to the best of my knowledge. By voluntary signing below, I show that I have read, or have read to me, the above consent to treatment, and have had opportunity to ask questions. I expressly assume all risks to me associated with any service offered by Ideal Body Clinic, and waive any claim which I might otherwise bring against Ideal Body Clinic, as a consequence of injuries resulting from or relating to my participation in one or more services. Please note that all products and services provided are not subject to refund. However, they can be exchanged or be credited the precedingly paid amount or the remaining balance.

Patient Signature*

Patient Information

Contact Information

Waiver of Liability and Informed Consent Release

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