Patient Details

First Name *

Last Name *

Phone *

Email *

Address *

City *

Postal code *

State *

Date of birth *

Reason for Appointment *

Pertinent Medical History (Including hospitalizations/surgeries) *

Please List All Medications Including Prescriptions, over the counter, vitamins, herbs/homeopathic supplements you are taking. Please specify dosage.

Please list any allergies to medications or food. *

Emergency Contact Information

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone *

Relation To Patient *

In the event a family member(s) or caregiver(s) attends my visit(s) and is in the exam area at the time of my evaluation and/or treatment, I give ELITE IV PLLC, its providers, and employees my permission to discuss freely care with that person(s) present. *

Yes

Today's Date *

I understand that intravenous therapy and any claims made about these infusions have not been evaluated by the U.S Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any medical disease. Infusions are not a substitute for your primary physician’s medical care.

For today’s procedure:

1. I understand that intravenous infusion involves the insertion of a needle into a vein and injection of the prescribed solution.

2. I understand possible alternatives to IV Therapy include but are not limited to oral supplements and/or dietary and lifestyle changes.

3. I understand the risks of IV Therapy include but are not limited to:

a) Occasional discomfort, bruising, and possible pain at the injection site

b) Rare inflammation of the vein used during the infusion, phlebitis, and metabolic disturbances.

c) Extremely rare allergic reactions, anaphylaxis, infection, cardiac arrest and death.

4. I understand other unforeseen complications could occur.

5. I do not expect the Elite IV, PLLC to anticipate and/or explain all risks and possible complications of intravenous infusions.

6. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered.

7. I understand I have the right to consent to or refuse any proposed/offered therapy, at any time prior to its administration.

By signing below, I acknowledge that I have been provided access to a copy of ELITE IV,

PLLC’s Notice of Privacy Practices.

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

procedures have been adequately explained to me, and I authorize and consent to the performance of procedures.

I release ELITE IV, PLLC including its providers and employees from all liabilities from any complications or damages associated with intravenous infusion therapy.