IV Client Consent Form Name * First Name Last Name Date of birth * Age Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact & Phone # How did you hear about us? Medical Questionnaire For Nutrient IV Therapy: Congestive Heart Failure Severe Renal Impairment Heart Attack / Stroke Condition of Sodium Retention or Electrolyte Imbalance Edema Water Retention High / Low Blood Pressure Severe Frequent Headaches Fainting / Seizures / Epilepsy Diabetes / Low Blood Sugar Any liver conditions ( e.g. Liver Cirrhosis, Liver Disease) Any allergies Sulfa Allergies Asthma None of the above Any other medical history? Terms, Conditions & Consent for IV Hydration Therapy I understand that Thank you!
