Client Consent Form

Client Consent Form
Name

First Name Last Name
Procedure
1. Patient provides facilities and personnel to assist your physician in the performance of intravenous therapy. You have the right to be informed of the procedure, and feasible alternative options, and the risk and benefits. Except in emergencies, procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.
  1. The procedure involves inserting a needle into your vein or muscle and injecting the formula described above by your physician.
  2. Alternatives to intravenous therapy is ordal supplementation and/ or dietary and lifestyle changes.
    
    Risk of intravenous therapy include:
    Discomfort, bruising and pain at the site of injection
    
    Inflammation of the vein used for injection, phlebitis.
    
    Severe allergic reaction, anaphylaxis, cardiac arrest and death.
  3. Benefits of intravenous therapy include:
    
    Injectables are not affected by stomach or intestinal disease.
    
    Total amount of infusion is available to the tissues.
    
    Nutrients are forced into cells by means of high concentration gradients.
    
    Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
2. You have the right to consent to or refuse and proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to the procedure(s) described above with any different or further procedures which, in the option of your physician, may be indicated.
3. The procedure will be performed by or under the direction of the physician named above with qualified medical assistants.
Your signature below means that:
- You understand the information provided on this form and agree to the foregoing.
- The procedure(s) set forth above has been adequately explained to you by your physician.
- You have received all the information and explanation you desire concerning the procedure.
- You authorize and consent to the performance of the procedure(s).
Date

Month Day Year
Date Date Picker Icon
Time

: Hour Minutes AM/PM Option
Client/Represenative Signature

Clear
Witness

Clear
If signed by representative, indicate relationship
Date

Month Day Year
Date Date Picker Icon
Client Intake Form
Client Name

First Name Last Name
Date

Month Day Year
Date Date Picker Icon
Age
Sex
Referring Doctor
Frequency
Current health concern
Current medications
Date of last chemistry screen

Month Day Year
Date Date Picker Icon
Past Medical History - Has the patient ever been diagnosed with

Hypertension Angina Ankle Swelling Amythmia CHF MI Abnormal EKG Kidney dz Gen. Edema Bleeding Disorder Asthma Pulmonary edema Sudden weight loss DM Anxiety or panic attack Is patient pregnant? G6PD Deficiency
Client details of conditions checked above
Referring Dr. Signature

Clear
Client Intake Form (Con't)
Date of 1st Intake

Month Day Year
Date Date Picker Icon
Known allergens
Allergy to Latex?

Yes No
Allergy to Shellfish?

Yes No
Allergy to Iodine?

Yes No
Presence of Edema
Lung sounds
Heart sounds
Vital signs
BP
Pulse
Resp
Temp
Weight
Progress Notes
Name

First Name Last Name
Date

Month Day Year
Date Date Picker Icon

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Date of Birth

Month Day Year
Date Date Picker Icon
Age
Sex

Male Female
Occupation
Email
example@example.com
In case of emergency, who should we contact?
What are your main complaints?
Allergies
Have you had injections before

Yes No
If so, any problems?
Medications
Please check if you have any of the following:

Fatigue Weight issues Heart Disease Sleep Disorders Asthma Thyroid Disorders Low depressed mood Irritability/Moodiness Diabetes Osteoporosis Allergies IBS/Inflammatory Bowels Pernicious Anemia Pregnant/Trying to be Pregnant Memory Loss/Alzheimer's Tendonitis Immunosuppression Numbness or tingling of body
How did you learn about this service?

Already a Client Web Search Walk-in Sign Advertisement Referred Website Living Social
If you purchased a package: An injection will be deducted from your package for every missed appointment or late cancellation (less than 24 hours notice).
Potential benefits of Nutrient Injections
- More energy, mental alertness and stamina for everyday tasks
- Healthier Immune Sytem
- Improves sleep
- Increases metabolism, therby aiding in weight loss
- Reduces allergies, stress and depression
- Imporves mood stabilization
- Lessens frequency and severity of migrainness and headaches
- Helps lower homocysteine levels in the blood
Informed Consent for Treatment

I consent to all nutrient injections rendered by the doctor(s), medical assistants or nurses emplyed by or associated with Fleaux with Mo. I understand that there aree risks to vitamin nutrient injections including but not limited to opain, brusing, inflammation, injury, infection, allergic reactions, headaches, dry mouth, difficulty sleeping, diarrhea, blurred vision, unpleasant taste, increased urination, cramps, and metabolic disturbances. I do not expect the persons emplyed or associated with Fleaux with Mo to anticipate and or explain all risk and possible complications. I hereby realease the doctors at Fleaux with Mo from all liabilites regaurding my treatment with vitamin/nutrient injections. I understand that nutrient injections may not be approved by the United States Food and Drug Administration for the treatment of my medical condition.
Client Signature

Clear
Date

Month Day Year
Date Date Picker Icon
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Client Consent Form

Client Intake Form

Client Intake Form (Con't)

Potential benefits of Nutrient Injections

Informed Consent for Treatment