Name:

Date of birth:

Address:

Phone number:

Email:

Please read this consent form thoroughly. 

Please answer all questions. 

If you have any uncertainty regarding questions, please discuss with your doctor. 

Medical History Questionnaire:

1. Do you have any known allergies? (e.g., medications, foods, latex)

   - Yes ___ No ___

   - If yes, please list: _______________________________________

2. Are you currently taking any medications or supplements?

   - Yes ___ No ___

   - If yes, please list: _______________________________________

3. Do you have any chronic medical conditions? (e.g., diabetes, heart disease, kidney disease)

   - Yes ___ No ___

   - If yes, please list: _______________________________________

4. Have you had any recent surgeries or medical procedures?

   - Yes ___ No ___

   - If yes, please specify: _______________________________________

5. Do you have a history of intravenous (IV) therapy complications?

   - Yes ___ No ___

   - If yes, please describe: _______________________________________

6. Are you pregnant or breastfeeding?

   - Yes ___ No ___

7. Do you have a history of fainting or dizziness?

   - Yes ___ No ___

8. Do you smoke or use recreational drugs?

   - Yes ___ No ___

   - If yes, please specify: _______________________________________

Procedure Information:

IV vitamin therapy involves the intravenous administration of vitamins, minerals, and other nutrients to support health and well-being. This therapy aims to improve hydration, boost energy levels, enhance the immune system, and promote overall wellness.

Procedure Description:

- The procedure typically takes 30-60 minutes.

- A healthcare provider will insert an IV catheter into a vein, usually in the arm, to administer the vitamin solution.

- You may feel a slight pinch during the insertion of the needle.

- You will be monitored throughout the procedure to ensure your comfort and safety.

Potential Risks and Side Effects:

While IV vitamin therapy is generally safe, potential risks and side effects include:

- Pain, bruising, or swelling at the injection site

- Infection at the injection site

- Allergic reactions

- Dizziness or fainting

- Electrolyte imbalances

- Fluid overload

Before the Procedure:

- Inform your healthcare provider of any medical conditions, medications, or allergies.

- Hydrate well before the procedure.

- Avoid alcohol and caffeine on the day of the treatment.

After the Procedure:

- Continue to hydrate well.

- Monitor the injection site for any signs of infection (redness, swelling, warmth).

- Follow any additional instructions provided by your healthcare provider.

Consent:

I have read and understand the above information about IV vitamin therapy. I have discussed the procedure with my healthcare provider and have had all my questions answered to my satisfaction. I understand the risks and benefits associated with IV vitamin therapy and agree to proceed with the treatment.

By signing this form, I consent to receive IV vitamin therapy from Dr. BB Crook at Arcabee Aesthetics.

Patient Signature: ____________________________  Date:_____________

Healthcare Provider Signature:_______________  Date: _____________