Medical Pre-Screening & Consent

Please fill out the following Medical Pre-Screening Form and sign the consent before your IV Drip Appointment.

Your response does not disqualify you from getting an IV Drip, but might require additional medical clearance.

Informed Consent must be given by the patient unless they are a minor or has a health care proxy.
Patient must be awake, alert and oriented during the IV treatment.

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Are you pregnant or planning to be in the next 3 months?
Do you have any allergies to medication?
Are you taking any medication?
Have you tested positive for COVID-19 in the past 10 days or are you experiencing any flu-like symptoms?

Consent *

Informed Consent must be given by the patient unless they are a minor or has a health care proxy.
Patient must be awake, alert and oriented during the IV treatment.

I hereby authorize Menon Wellness  IV Drip and its staff including medical doctor, physician assistant, nurse practitioner, nurse or other clinical staff person to administer care.  Care includes but is not limited to, obtaining a medical history, physical examination including diagnostic procedures and provision of medical treatment. I understand my medical conditions may have an impact on the effectiveness of treatment thus I have shared an accurate health history with the clinical staff including but not limited to an overview of my medical conditions, allergies and medication list. 

 

I consent to the treatment and understand that all therapies have risks of injury. Potential risks to infusion therapy include but  are not limited to pain at the injection site, bleeding, swelling, infection, allergic reaction, bruising, lightheadedness, syncope and severe adverse reactions.  I acknowledge I am aware of these risks and I do not have the expectation that any practitioner can predict all the potential risks and complications. I understand that Menon Wellness IV Drip can not guarantee this treatment nor its results on my overall health. Vitamin infusions are used to supplement health but are not validated by the Food and Drug administration or any other health agency for efficacy or quality.  As such, I understand the infusion is not meant to treat, cure or diagnose any disease. I voluntarily consent to treatment without coercion.  

 

I hereby consent to the performance of intravenous treatment or other medically necessary treatments done in the office, home, or other designated area of care.  I have had the opportunity to review the nature and purpose of treatment as well as risks and benefits to treatment. 

 

I assume responsibility for all expenses incurred in the treatment.

 

I hereby hold Menon IV Drip any affiliated members free and harmless from any claim of damage that might arise in the process of providing medical care to myself or other designee. My signature indicates that I have read this document in its entirety and accept services with full knowledge.