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Medical form and waiver

Please fill out the medical form and IV hydration waiver before infusion.

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?

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IV Consent form

Please fill out the following form.

Informed Consent for Intravenous (IV) Therapy

This document is intended to serve as confirmation of informed consent for IV therapy as ordered by Elevation Hydration P.C. **I have informed the staff of any known allergies to drugs or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics.** **I have informed the staff of all current medications and supplements.**

I understand that I have the right to be informed during the procedure, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. The IV intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time, prescribed nutrients (vitamins, minerals, amino acids). I understand that risks, benefits and alternatives to IVs may include but are not limited to: 1. The Risks and potential side effects ○ Discomfort, bruising, and pain at the site of injection. ○ Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. ○ Severe reaction, anaphylaxis, cardiac arrest, or death. 2. The Benefits ○ Injectables are not affected by stomach or intestinal disease. ○ Total amount of infusion enters the bloodstream and is available to the tissues ○ Safe but higher doses of nutrients can be given by vein than by mouth without intestinal irritation that can accompany doses given by mouth. 3. Alternatives to intravenous vitamin therapy are oral supplementation and/or dietary and lifestyle changes. I am aware that other unforeseeable complications could occur. I do not except the nurse to exercise judgement during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. 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 therapy with any different or further procedure, which in the opinion of Elevation Hydration PC. or other(s) associates of Elevation Hydration PC., may be indicated. I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above has been adequately explained to me by my Practitioner. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials. My signature below confirms that: 1. I have received all the information and explanation I desire concerning the procedure. 2. I authorize and consent to the performance of the procedure(s)Assumption of risk naming Learfield / Wyoming Sports Properties and the University of Wyoming”

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