HEALTH SCREENINGPlease complete the following questionnaire to assure that we can provide you with the safest care possible. Name * First Name Last Name Email * Phone Number * (###) ### #### Date of Birth * MM DD YYYY Address * Emergency Contact Name * Emergency Contact Number * (###) ### #### Health Assessment Are you currently pregnant or breast feeding? * YES NO List any food or drug allergies: * Do you have any of the following health conditions? * High Blood Pressure Palpitations Heart Failure Diabetes Kidney Disease Thyroid Disease Liver Disease None Have you ever been told you have an Electrolyte Imbalance? * YES NO Please list all current medications (prescription, over the counter, and/or supplements) * Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? * YES NO Thank you! CONSENT FORM Consent Form Name * First Name Last Name Date * MM DD YYYY Email * Acknowledgment and Consent * This document is intended to serve as confirmation of informed consent for IV therapy as ordered by Nicole Imbasciani ANP-C for Rock Star Recovery and Wellness. I have informed the provider of any known allergies to drugs, supplements or other substances that may be included in the ingredients of these solutions, or of any past reactions to anesthetics. In doing so, I understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with me in so far as to the extent to which I do not disclose those allergies in advance. I have informed the provider of all current medications and supplements. In doing so, I understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with me in so far as to the extent to which I do not disclose my health conditions, medications or supplements in advance. I have informed the provider of all medical conditions, diseases and illnesses. I attest that I have never been diagnosed with or treated for any such conditions that would put me at increased risk while receiving IV therapy services by Nicole Imbasciani ANP-C for Rock Star Recover and Wellness. I understand that I will be screened for said conditions prior to initiation of services. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such treatment rest entirely with me to the extent that I do not disclose my health conditions, medications or drug use in advance. I understand that I have the right to be informed of the risks and benefits before therapy administration. No procedures will be performed until I have had an opportunity to receive such information and to give my informed consent. These therapies are not intended for emergency care or for the medically ill. The intravenous (IV) procedure involves inserting a needle into your vein and infusing the prescribed nutrients and/or medications over a determined period of time. That time will vary depending on your anatomy and infusion rate; however the therapy should be expected to take about 30 to 60 minutes. I understand that IV therapy carries with it both risks and benefits. Some of those risks and benefits include, but are not limited to: The Risks and potential side effects 1. Discomfort, soreness, bleeding, bruising, pain and possible scaring at the site of injection 2. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury 3. Lightheadedness or fainting 4. Severe reaction to medication, supplement or vitamin therapy; anaphylaxis, cardiac arrest or death. 5. Volume overload. 6. Air Embolism. 7. Infiltration. The Benefits 1. Injectables are not affected by stomach or intestinal disease. 2. Total amount of infusion enters the bloodstream and is available to the tissues. 3. Higher doses of nutrients can be given by vein than by mouth. 4. Can be used in conjunction with oral supplementation and/or dietary and lifestyle changes. I am aware that other unforeseeable complications could occur. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time before or during its performance. My acknowledgement of this form affirms that I have given my consent to IV therapy with any different or additional procedure/medications, which in the opinion of Nicole Imbasciani ANP- C or other(s) associated with Rock Star Recovery and Wellness, may be indicated. We are committed to your privacy and all health care information provided to Rock Star Recovery and Wellness will be protected in accordance with federal HIPAA guidelines. The information provided is for review by Nicole Imbasciani ANP-C and other heath care providers associated with Rock Star Recovery and Wellness. I understand the information provided on this form and agree to all therein. I understand that there are no implied or stated guarantees of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. I understand that I am free to withdraw my consent and discontinue participation in their treatments at any time. My completion of this informed consent will constitute a full and final release of any legal responsibilities of Nicole Imbasciani ANP-C and any and all licensed health care providers associated with Rock Star Recovery and Wellness as it relates to IV therapy and any other medical treatments provided. I acknowledge the risks and benefits and consent to IV Treatment. Thank you!
