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:

  1. Immediate rehydration, replacement of vitamins, minerals, amino acids, nutrients, and antioxidants that are available immediately via the bloodstream to the tissue.
  2. Injectables are not affected by stomach or intestinal disease
  3. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

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)

  1. Infection, swelling at phlebitis at the site (rarely).
  2. Severe allergic reaction, anaphylaxis, infection, cardiac arrest or death (rarely)

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.

OUR PRODUCTS AND SERVICES ARE NOT A TREATMENT FOR ANY SERIOUS MEDICAL CONDITIONS


Client Phone:


Client Name:

Leave this empty:

Signature arrow
Signature Certificate
Document name: Medical Consent Form
lock iconUnique Document ID: 833771e7e1e9f35cf6468da694d128414df118cc
Timestamp Audit
September 4, 2019 9:33 am ESTMedical Consent Form Uploaded by Jamie Larkin - info@ivmenowfl.com IP 73.105.40.224
September 4, 2019 9:35 am ESTDonnie Strompf - donnie@goodatmarketing.com added by Jamie Larkin - info@ivmenow.com as a CC'd Recipient Ip: 37.120.157.44
September 9, 2019 12:03 pm ESTDonnie Strompf - donnie@goodatmarketing.com added by Jamie Larkin - info@ivmenow.com as a CC'd Recipient Ip: 23.82.136.226
September 25, 2019 10:16 am ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenow.com as a CC'd Recipient Ip: 185.245.86.86
October 15, 2019 4:10 pm EST Document owner info@ivmenow.com has handed over this document to info@ivmenowfl.com 2019-10-15 16:10:19 - 68.94.176.76
October 15, 2019 4:10 pm ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenowfl.com as a CC'd Recipient Ip: 68.94.176.76
October 15, 2019 4:17 pm ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenowfl.com as a CC'd Recipient Ip: 68.94.176.76
October 15, 2019 4:18 pm ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenowfl.com as a CC'd Recipient Ip: 68.94.176.76
October 15, 2019 4:19 pm ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenowfl.com as a CC'd Recipient Ip: 68.94.176.76
October 15, 2019 4:21 pm ESTJamie Larkin - info@ivmenowfl.com added by Jamie Larkin - info@ivmenowfl.com as a CC'd Recipient Ip: 68.94.176.76