IV Therapy Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Are you currently taking (or have recently been taking) any dietary supplements or vitamins? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or possibly may be) pregnant or breastfeeding? *

Do you have any inflammation or infection in the area of the insertion site? *

Do you have any history of the following? Please tick all that apply.

If you have ticked any of the above please give details:

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following have you been unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Treatment Information

What is IV Therapy?

IV Therapy, also known as intravenous therapy, is the administration of delivering nutrients and hydration directly into the bloodstream for immediate absorption and use by the body.

IV Therapy is the fastest way to deliver nutrients throughout the body, because it bypasses the digestive system and goes directly into the organs, resulting in a 90-100% absorption rate (as opposed to only 20-50% possible orally).

The stress of modern living can lower your immune system and general wellbeing: IV Therapy can give that much-needed boost, making it a realistic and practical option.

While stress alone doesn’t cause us to catch a cold or a flu virus, it definitely weakens the immune system’s ability to respond to viruses, leaving us more vulnerable to infection and illness.

So, if you want to boost your immunity, replace lost fluids and electrolytes after a boozy night out or support recovery from high-performance athletics – IV Vitamin Therapy can help to restore your body’s nutrient levels to their optimal state.

What Are the Benefits of IV Therapy?

One of the main benefits of IV Therapy is fast, more effective results without gastrointestinal side effects, absorption issues or loss of potency.

The process allows the nutrients to go right into your bloodstream, bypassing the digestive system allowing you to have more energy, think more clearly, and enjoy a better mood.

The benefits will differ depending on the condition treated, the protocol used, the overall health of the client, and how many treatments are done. Some reported benefits include:

Stronger immunity (warding off a cold or flu)
Enhanced mood
Increased sports recovery time
More energy
Improved concentration and mental focus
Increased calmness and relaxation
Balanced blood sugar
Improved sleep patterns
Improved jetlag
Improved hangover
Reduced instances of migraines
Boosted fertility and hormonal imbalance
Improved complexion
Reduced signs of ageing

How Long Does the IV Therapy Effects Last?

Typically, the effects become fully noticeable after the 12 – 24 hours after infusion, although many people report feeling better right after treatment.

The effects last for 8 days to 3 weeks depending on the condition, cocktail and type of IV Therapy.

Potential Risks and Side Effects

Is IV Therapy Safe?

Today, the administration of intravenous fluids via IV infusion is common and generally safe, but it is possible to have too much of a good thing, which can increase the risk of adverse effects.

If you have any medical condition, it is always advised to consult with your healthcare provider (i.e. GP or Consultant) prior to treatment to avoid any complications.

Complications of IV Therapy

While IV treatment is relatively safe, there can be complications. The most common include:

Discomfort, pain and bruising at the injection site - Occasionally to commonly
Inflammation in the vein used, phlebitis, metabolic disturbances - Rarely
Severe allergic reaction, anaphylaxis, systemic infection, cardiac arrest and possible death - Extremely rarely

Please tick each statement to show your understanding and agreement. *

I am aware that other unforeseeable complications could occur. I do not expect the clinic to anticipate and/or explain all risk and possible complications. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

Consultation

Have you previously received IV Therapy? *

How was your experience? *

What are your main reasons for seeking IV Therapy? *

Do you have a phobia of needles? *

Aftercare Advice

The following aftercare advice is essential to help reduce the risk of treatment complications, to improve your comfort/healing and to help achieve the best possible results from treatment.

Please follow the aftercare advice for IV infusion therapy.

You may have some localised tenderness and swelling in the site that the venous cannula was inserted afterwards, this should usually resolve within 48 hours.
You may experience bruising in the site that the venous cannula was inserted. Bruising is common and may take 1-2 weeks to resolve.
Keep the area where the cannula was inserted clean afterwards.
Drink plenty of water to stay hydrated after treatment for the next 48 hours.
In the unlikely event of bleeding afterwards from the cannula site, sit quietly and apply firm pressure to the area for 20 minutes. You can use a swab, clean cotton wool pad, a clean towel or flannel. Seek medical attention if bleeding will not stop, this is extremely unlikely.
You must seek medical attention and contact your practitioner if you experience any signs or symptoms of skin infection after the treatment. Infection can present as hot, red shiny skin, there may be pus formation and you may have a fever or feel generally unwell.
You must contact your practitioner as soon as possible if you experience any other unwanted side effects after having the IV infusion.
Seek medical attention if you feel unwell following the infusion.
Seek emergency medical attention in the rare event that you experience any severe allergy signs or features of anaphylaxis after IV infusion treatment. These may include rash, facial swelling and breathing difficulties.

It is essential that you have read all of the information available. Please do let your practitioner know if you have any questions or if you do not understand any of the aftercare instructions provided above.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

Please read the following information carefully.

Intravenous (IV) Therapy is designed to improve your optimum health, absent of other non-nutritional complicating factors, and requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. It is NOT intended to make a medical diagnosis and to recommend any medicinal treatment(s).

No comment or recommendation should be construed as inferring or implying a medical diagnosis. SInce every person is unique, we cannot guarantee any specific result from IV Therapy. Medication and/or medical conditions may have a negative impact on the positive effects of IV Therapy.

If you suffer from a medical condition you need to consult with an appropriate healthcare provider such as your GP or Consultant before receiving IV Therapy. It is important that you inform your healthcare provider of your use of IV Therapy. IV Therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important that you always keep your healthcare provider informed of changes in your nutritional programme.

Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your programme as we proceed until your body can begin to properly accept products required to correct possible imbalances. It is your responsibility to do your part by following healthy dietary guidelines, exercise your body if possible, get plenty of rest, and learn more about nutrition health benefits.

Please read each statement carefully and tick to show your agreement. *

I understand that the procedure involves inserting a needle into a vein and injecting the selected product. I understand that alternatives to IV Therapy are oral supplements and/or dietary and lifestyle changes. I understand that several supplementation sessions may be required. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. I understand that at any stage during the infusion/injection I have the right to request that the procedure is terminated however I accept that I will not be re-imbursed once supplementation has commenced.

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I fully understand the above and consent to the IV Therapy treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign