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IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
Home
About Us
Services Offered
IV Infusion Consent
NAD+ IV Therapy
IV Infusion Therapy
Medical Screening Checklist
Contact
Book Now
NAD+ IV Therapy
NAD+ IV Therapy Medical Screening Checklist
Patient Name
Date of Birth
Date
Email Address
Absolute Contraindications
Pregnancy or breastfeeding
Active cancer treatment
Uncontrolled cardiac disease
Severe kidney disease
Severe liver disease
Relative Contraindications:
Anxiety or panic disorder
History of chest pain
Migraine disorder
Autoimmune disease
Other Diagnoses (Please List):
Current Medications / Supplements
Vital Signs
BP:
HR:
SpO
2
Infusion Duration Acknowledgement
Patient understands NAD+ infusion may last 1–4 hours
RN Determination
Cleared for NAD+ infusion
Requires Medical Director approval
Not appropriate today
RN Signature
Date
Medical Director Approval
Date
Submit
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