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IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
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Home
About Us
Services Offered
IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
Book Now
IV Infusion Therapy
IV Infusion Therapy Contraindication Checklist
Patient Name
Date of Birth
Date
Email Address
Absolute Contraindications (Do Not Treat)
Congestive Heart Failure (CHF)
End-Stage Renal Disease / Dialysis
Renal Failure
Active Infection or Sepsis
Uncontrolled Hypertension
Known Allergy to IV Components
G6PD Deficiency (Vitamin C)
Current Chemotherapy without clearance
Altered Mental Status
Relative Contraindications (Medical Director Approval Required):Contraindications:
Pregnancy or Breastfeeding
Asthma or Severe Allergies
Diabetes Mellitus
Liver Disease
Cardiac Arrhythmias
Seizure Disorder
Poor Venous Access
Current Medications
Vital Signs
Blood Pressure:
Heart Rate:
SpO
2
Patient Signature
Date
RN Signature
Date
Medical Director Signature
Date
Submit
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