IV Vitamin Infusion Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Gender Male Female Email * Phone * (###) ### #### Have you received IV Vitamin Infusions before? YES NO Please indicate if you have any of the diagnoses below High Blood Pressure CHF MI / Heart Attack Ankle Swelling G6PD Deficiency Arrhythmia Low Blood Pressure Diabetes Kidney Disease Anxiety Edema Sudden Weight Loss Abnormal EKG Angina Bleeding Disorder Asthma Congestive Heart Failure Cancer Other Can you provide a list of health conditions or medical concerns to be evaluated for the potential benefits of IV Therapy? Fatigue Weight Issues Stress Sleep Disorders Low Immunity Migraines Low / Depressed Mood Irritability / Moodiness PMS Asthma Digestive Issues Muscle Spasms Anemia Trying to get pregnant / Fertility prep Allergies IBS / Inflammatory bowels Numbness / Tingling of the Body Aging Other Provide a list of all known and suspected allergies Please list any prescription drugs and supplements you are currently taking How did you hear about us? Additional notes Patient Acknowledgment & Consent Form I hereby give Comeback Orthopedics and Infusions/ Chad Poage, D.O. and all associated providers and staff permission to evaluate and treat me. I understand this is a public event, however Comeback Orthopedics and it's providers comply with HIPPA and protect my information. Checking this box and clicking submit to this form acts as my electronic signature and consent. I acknowledge and consent Thank you!
