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About Us
Services Offered
IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
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IV Infusion Consent
Informed Consent for IV Infusion Therapy
Patient Name
Date of Birth
Email Address
Phone Number
Emergency Contact
Date
I authorize KCL Infusion LLC to administer intravenous (IV) fluids, vitamins, minerals, and/or medications as ordered by the Medical Director and administered by licensed medical personnel. I understand IV infusion therapy involves placing a catheter into a vein and that risks may include pain, bruising, infection, infiltration, dizziness, nausea, allergic reactions, phlebitis, or fluid overload. I understand IV therapy is not a substitute for primary medical care and that results are not guaranteed.
Services are provided in a mobile, non-clinical setting. In the event of an emergency, Emergency Medical Services (911) will be activated.
I confirm I have disclosed all relevant medical history, medications, supplements, allergies, and pregnancy status.
Patient Signature
Date
RN Signature
Date
Medical Director Signature
Date
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