1. Introduction
You are being offered IV (intravenous) hydration therapy to replenish fluids, vitamins, and electrolytes directly into your bloodstream. This consent form provides information to help you understand the benefits, risks, and responsibilities associated with IV hydration therapy.
2. Purpose of IV Hydration
To improve hydration and electrolyte balance.
To potentially alleviate symptoms such as fatigue, headache, or dehydration.
May be used for athletic recovery, immune support, or as recommended by a healthcare professional.
3. Possible Benefits
Rapid delivery of fluids, vitamins, and electrolytes.
May lead to increased energy levels, improved recovery times, and overall well-being.
Can address acute dehydration more efficiently than oral intake of fluids.
4. Risks and Possible Complications
As with any medical procedure, IV hydration therapy has potential risks, which can include but are not limited to:
Injection Site Complications: Bruising, swelling, redness, or pain at the IV site.
Infiltration/Extravasation: Leakage of IV fluids into surrounding tissues, which may cause discomfort, swelling, or tissue damage.
Infection: Risk of infection at the injection site.
Allergic Reactions: Rare but possible reactions to components of the IV fluid, medication, or vitamins.
Phlebitis: Inflammation of the vein.
Fluid Overload: If too much fluid is administered or in patients with underlying conditions like congestive heart failure.
Dizziness or Lightheadedness: Especially if you are dehydrated or have low blood pressure.
Contact your healthcare provider immediately if you experience any severe or concerning side effects during or after the therapy.
5. Contraindications
You may not be eligible for IV hydration therapy if you:
Have certain heart or kidney conditions.
Have known allergies to the components of the IV solution.
Are pregnant or breastfeeding (consult your provider first).
Inform your healthcare provider of any medical conditions, medications, or supplements you are taking prior to receiving IV therapy.
6. Patient Responsibilities
Provide Accurate Medical Information: Disclose all health information, including past medical history and current medications.
Follow Recommendations: Adhere to any guidelines given by your provider before or after your infusion.
Report Any Discomfort: Immediately inform staff if you experience pain, burning, or other unusual sensations at the IV site.
Stay Hydrated and Monitored: Drink water and follow aftercare instructions as directed.
7. No Guarantee of Results
IV hydration therapy outcomes can vary. While many patients experience beneficial effects, no specific results (e.g., improved energy, total symptom relief) are guaranteed.
8. Confidentiality
All medical records and information regarding your treatment will remain confidential in accordance with HIPAA regulations.
9. Financial Responsibility
You are responsible for any costs associated with this service as outlined by your insurance policy or self-pay agreement.
10. Patient Acknowledgment and Consent
I, the undersigned, hereby acknowledge that I have read (or had read to me) and understand the information contained within this consent form. I have been informed of the potential risks, benefits, and alternatives to IV hydration therapy. I agree to release [Your Clinic Name] and its staff from liability for any complications that may arise, except in the case of negligence.
.png)