IV Drip Forms - A Good Drip

A GOOD DRIP

IV HYDRATION

(888) 698 DRIP

Pre and Post Visit Instructions

To have a safe and effective IV therapy session, it is important that you adhere to the following pre- and post-visit instructions.

Before your appointment:

Plan to be at the clinic at least 15 minutes before your infusion to fill out necessary paperwork if you are a first-time patient.
- If you are a repeat patient, then arrive 5 minutes before infusion.
You can take your regular medications as normal on the day of treatment. If you are taking any of the following medications, you must hold them the day of your treatment: (Please specify if any)

After your IV infusion:

Continue to wear dressing applied to the IV infusion site for 1 hour to prevent break through bleeding.
You can apply cold packs or take naproxen (Aleve) for any post injection/infusion pain.
A light meal and 16 ounces of water are recommended after the infusion.
Monitor your IV site for redness, pain, warmth, or swelling. This could be a sign of infection or an adverse reaction. If this occurs, please call A Good Drip at (888) 698-DRIP.
Continue routine follow up with your mental health and/or primary care provider for continued treatment and evaluation.
If any mild side effects occur such as hives, nausea, fever, cramping, headaches, or any additional non-life-threatening symptoms, please call A Good Drip at (888) 698-DRIP immediately. If it is after hours, then please report to your closest urgent care or emergency department.
If any type of serious adverse events occurs such as diffuse hives, shortness of breath, trouble swallowing, chest pain, severe headache, changes in consciousness, increase pain/swelling in the arm that the infusion was given in, or anything else that is concerning, call 911 or report to the emergency department immediately.
You can expect to feel improvements in your symptoms within 15-90 minutes of your infusion. These effects can last up to 1 to 1 and a half weeks.
Patients can present for repeat infusions every 2 weeks unless determined otherwise by your treating provider.

If you have any additional questions or concerns, please feel free to reach out to A Good Drip LLC.

Acknowledgment & Details

Your next appointment date and time (if known):

Additional instructions/notes (from staff or patient):

Printed patient name:

Patient signature (type full name):

Date:

I acknowledge that I understand the instructions that need to be followed prior to and after my treatment. I certify that I will follow these instructions and notify A Good Drip LLC of any changes in my condition or drug/supplement use.

Client Consultation Form

Intravenous Infusion Therapy

Visit Information

Date:

Time:

Client Details

Name:

Date of Birth:

Contact Number:

Email:

Address:

Preferred method of contact:

Email

Call

Text

Emergency Contact Number:

Medical History

Have you ever had IV Hydration Therapy before?

Yes

No

Are you currently pregnant?

Yes

No

Certain conditions may affect how appropriate the treatment is. Please declare all relevant history as some conditions contraindicate the treatment.

I acknowledge I have declared all relevant history.

Consent for IV Therapy

IV (Intravenous Infusion) Therapy is the process of administering nutrients and Vitamins through the vein directly to the blood stream. IV Therapy allows a higher concentration of nutrients to enter the blood stream in a short period of time versus taking supplements orally.

Risks and Complications: With every treatment there are risks involved. It is important that you understand the risks prior to undergoing treatment. Ensuring you provide a full medical history can reduce these risks but even so there may be unforeseen risks that are presented. If you have any concerns regarding these risks, do not hesitate to contact your Healthcare Professional. Risks include: Phlebitis, Extravasation, Infiltration, Infection, Swelling, Fluid Overload, Rashes, Speed Shock, Anaphylaxis, Air-Embolism, Sensitivity, Bruising, Electrolyte Imbalance.

Consent Statements:

During the treatment, despite all the precautionary measures made by the Healthcare professional injury is possible. I will not hold the Technician performing this service on me responsible in any issues that may arise due of having the procedure performed on me.
I consent to the insertion of a peripheral intravenous catheter (Cannula) and to the infusion of fluids, vitamins, mineral and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion.
I understand a Cannula will need to be inserted into my skin to gain access to the vein by the Healthcare Professional. My Healthcare Professional will have full competency in inserting a Cannula, removing a Cannula, monitoring and caring for the Cannula and administering Intravenous vitamins, minerals and/or medications.
I understand that there are risks associated IV Therapy, if any sort of reaction occurs I will seek medical attention and inform my Healthcare Professional.
It is my responsibility to advise the Healthcare Professional of any concerns I may have before the procedure.
I understand and agree to the aftercare instructions provided by the Healthcare Professional. By not following the aftercare instructions I am aware that the desired results may not be achieved.
I understand that there is a high risk of bruising to the Cannula site where the administration takes place.
The Technician performing the procedure will not be held liable for and damages caused to me or my skin by any reason, including allergic reaction, skin sensitivity, and failure to follow the after care instructions.
I have declared all relevant history, and if any changes occur in the future I will notify my Technician.

I have read and agree to the consent terms above.

Photo & Video Release

I give permission, without expecting payment, for use of photographs/videos.

I understand that I can withdraw my consent at any time.

Payment & Agreement Confirmation

Print name:

Signature (type full name):

Date:

By signing, I confirm that I have read and fully understand this agreement.

A GOOD DRIP

IV HYDRATION

IV Infusion and Injection Consent Form

Acknowledgments (Please check each point)

I understand that IV infusion and injection therapy at A Good Drip is not intended to diagnose or treat a specific medical condition.

I understand that IV infusion and injection therapy will not prevent, treat, or cure any medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing.

I have informed A Good Drip (including my name, and nurses' names) of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.

I understand that IV and injectable therapy and any claims made about these treatments have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. I understand that these treatments are not FDA approved for any given indications of treatment and are not considered a medical necessity.

I understand that I have been informed of the procedure involving IV infusion and injections, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.

I understand that the procedure involves inserting a needle into a vein or having a solution injected into my muscle or body fat.

I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.

I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels.

I understand that rare side risks involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.

I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract, increased total body hydration, alleviation of certain symptoms, increased total body nutrient density, and improved performance/recovery.

I affirm that I am voluntarily seeking IV infusion and injection therapies at A Good Drip and have not been coerced into doing so.

I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction.

I understand that unforeseeable complications can arise when an IV is placed and medications/fluids/minerals/vitamins are infused into the body.

I understand that I have the right refuse any treatments or treatment recommendations at any time.

Voluntary Nature of Treatment and Alternative Therapies

Signature (type full name):

Date:

Final Patient Consent for Treatment

I have had the nature of the procedure and/or treatment, the benefits of treatment, the risks of treatment, the side effects, the alternative therapies for my medical condition or symptoms I am seeking treatment for, and the chances of treatment success explained to me. I have had all my questions and concerns answered to my satisfaction. I acknowledge that I have been given sufficient information about IV hydration/vitamin/mineral/nutrient infusion and injection therapy and all its associated risks and benefits upon which to make an informed decision about treatment.

I acknowledge that there are no guarantees regarding the results of treatment and its effect on my presenting condition.

I give my consent for the use of emergency intervention if required during treatment.

I certify that I am of sound mind and body to make medical decisions and to consent for treatment.

I certify I will continue to remain under the care a licensed and qualified primary care provider and/or mental health provider as IV infusion and injection therapy is considered an adjunctive and non-medically necessary treatment option, not a complete one.

I release A Good Drip and all the medical staff from all liabilities for any complications or damages associated with IV infusion and injection therapy.

I have read this consent and fully understand the information within it and I voluntarily authorize and consent to the treatment options, including but not limited to IV infusion therapy, provided to me at A Good Drip.

Signature (type full name):

Date:

IV Drip Patient Forms

Pre and Post Visit Instructions

Client Consultation Form

IV Infusion and Injection Consent Form