Medical Consent Form
Informed Consent Form for Intravenous (IV) and Intramuscular (IM) Therapy
I, , hereby authorize the staff at the IVmenow Mobile IV van to administer either IV and/or IM therapy. I have made known to IVmenow staff of any medical history, medications, allergies or past reactions that may interfere with therapy.
Please list any allergies that you have.
Please list any existing conditions that you have.
I understand that these therapies involve inserting of a needle/catheter into either the vein or muscle. I understand that it is my responsibility to notify the staff of any burning, pain, or adverse reaction that I may be experiencing.
I understand that with IV therapy it is possible that if the catheter becomes dislodged or infiltrated that it may cause swelling, pain or discomfort at the site however, this is not dangerous to me or my health and that the fluids will absorb and the swelling and tenderness will subside.
The advantages of IV/IM therapy include:
I understand that there is no implied or stated of guarantee of success or effective of any specific treatment.
The disadvantages of IV/IM therapy may include:
Pain, discomfort, bruising at the injection site (occasional)
Alternatives to IV/IM therapy include oral supplementation, lifestyle and dietary changes
I am aware that unforeseeable complications could occur and that IVmenow mobile IV van/ staff is and are not an ambulance service nor equipped to handle life-threatening emergencies. If the event of any unforeseen severe reaction, 911 will be notified. 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/IM therapy.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Medical Consent Form
Agree & Sign