INTRAVENOUS (IV) WELLNESS THERAPY INTAKE FORM
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What are your main concerns? (please check all that apply)

Fatigue or low energy
Asthma and/or Allergies
Recent or future surgical procedure
Poor diet due to busy lifestyle
Recent illness
Brain fog or trouble concentrating
Cold or flu-like symptoms
Low mood or depression
Facial wrinkles or fine lines
Headaches or migraines
Exercise Recovery
Premenstrual syndrome(PMS) symptoms
Hangover or dehydration
Jet Lag
Other 

Medical History

YesNo
Hypermagnesemia (High Magnesium levels)
Hypercalcemia (High Calcium levels)
Hypokalemia (low potassium levels)
Hemochromatosis (High iron levels)
Other 
Yes No
Yes No
Yes No

Please list everything you are currently taking:

MEDICAL HISTORY CONTINUED

Yes No
Yes No
Yes No
Yes No

Do you have any of the following conditions?*

Yes (Please check all that apply) No
Blood pressure problems (High or low)
Heart Problems
Stroke or "mini-stroke"
Kidney Problems
Kidney Stones
Asthma
Optic Nerve Atrophy or Leber’s Disease
Sickle Cell Anemia
G6PD Deficiency
Sarcoidosis
Parathyroid problems (High levels)
Liver Disease
Renal Failure
Congestive Heart Failure
Intravenous (IV) Infusion Therapy Consent Form

This document is intended to serve as informed consent for your Intravenous (IV) Infusion Therapy as ordered by the physician at Five Journeys.

(Initials)* I have informed the nurse and/or physician of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or physician of my medical history.

(Initials)* Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.

(Initials)* I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

(Initials)* I understand that:

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.

2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.

3. Risks of intravenous therapy include but not limited to:

  • a) Occasionally: Discomfort, bruising and pain at the site of injection.
  • b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
  • c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
4. Benefits of intravenous therapy include:
  • a) Injectables are not affected by stomach, or intestinal absorption problems.
  • b) Total amount of infusion is available to the tissues.
  • c) Nutrients are forced into cells by means of a high concentration gradient.
  • d)Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

(Initials)* I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

(Initials)* I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

My signature below confirms that:

1. I understand the information provided on this form and agree to all statements made above.

2. Intravenous (IV) Infusion Therapy has been adequately explained to me by my nurse and/or physician.

3. I have received all the information and explanation I desire concerning the procedure.

4. I authorize and consent to the performance of Intravenous (IV) Infusion Therapy.

5. I release Dr. Levitan at Five Journeys, and all the medical staff from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.