Consent Form | Bandon Iv Lounge

Health Screening & Informed Consent Form

Please have every member of your group fill out this form

First name

Last name

Birthday

What are your chief concerns/goals for seeking IV therapy?

What is your desired outcome?

Please indicate below if you have been diagnosed with any of the following:

High blood pressure, low blood pressure, bleeding disorder, abnormal heart rhythm, angina, ankle swelling, anxiety, cancer, heart attack, kidney disease, liver disease, congestive heart failure, diabetes, asthma, edema.

Chronic conditions:

Do you have any other medical issues not listed above?

Have you had any hospitalizations or had any surgeries in the past month?

Are you currently pregnant, trying to get pregnant, or breastfeeding?

Are you experiencing an active infection?

Please indicate below if you have had any of the following abnormal lab results: elevated creatinine, hemochromatosis (high iron), iron deficiency, hyper or hyponatremia (high or low sodium), hyper or hypomagnasemia (high or low magnesium), or hyper or hypokalemia (high or low potassium).

Abnormal labs:

Please list all medications you are currently taking (include herbal, over the counter, topical, and supplements); doses not needed.

Are you currently taking antibiotics, anti-inflammatories, blood thinners, chemotherapy, corticosteroids, digoxin, diuretics, immunotherapy, or insulin?

Do you have any allergies to food, medications, or supplements?