New Patient Intake & Consent — Infusion Wellness Center

Personal Information

Please print clearly.

First name *

Last name *

Date of birth *

Sex

Email *

Cell phone *

Home phone

Work phone

Address *

Address line 2 (apartment, suite, unit)

City

State

ZIP

Do not leave a message on:

Home phone Work phone Cell phone

Responsible party

Same as patient (I am the responsible party)

First name

Last name

Date of birth

Patient's relationship to responsible party

Emergency contact

First name

Last name

Phone

Relationship

How did you hear about us?

Financial policy

I understand that Infusion Wellness Center does not accept insurance. Upon request, I will be given a receipt that I may submit to my insurance for possible reimbursement. I understand that if I cancel within 24 hours or do not show up for an appointment, I will be billed the entire amount of the appointment. I have been given the opportunity to ask questions regarding this statement.

I acknowledge and agree to the financial policy above. *

Practice policies

Please read and acknowledge below.

Initial interview: Your first history and physical is an evaluation interview and exam. We will decide together whether IV therapy is appropriate, the frequency of sessions, and your goals of therapy.
Appointments: Length varies by treatment. A 40-minute infusion appointment typically takes just under 2 hours; a 4-hour infusion is typically around 5 hours.
Cancellations: Please give as much notice as possible.
Payments: Payment in full is appreciated prior to the start of your appointment. We accept card, cash, and check (payable to "Infusion Wellness Center").
Insurance: We do not directly participate with insurance plans but will provide receipts and documentation to assist you. Payment for services is ultimately your responsibility.
Confidentiality: Your information is kept confidential and we follow HIPAA. Providers may use specialty consultation with other providers at the office as needed.

I have read and understand the foregoing statements and agree to abide by all of the above conditions. * I have received a copy of the Privacy Practices form. I consent to the exchange of treatment information between Infusion Wellness Center and my primary care or mental health provider.

History & Physical

Allergies

Current medications

Have you ever had a nutrient IV infusion?

No Yes

Any problems with prior infusions (reactions, allergies, access issues)?

What condition are you looking to address and/or what is your wellness goal?

Do you have any of the following conditions? (check all that apply)

Have you been told you need to start dialysis, or are you currently on dialysis?

Yes No

Are you taking, or been told you need to take, Digoxin?

Yes No

Are you of African, Middle Eastern, or Asian descent?

Yes No

Have you been told you have a decreased GFR or kidney problem?

Yes No

Nutrient infusion informed consent

Please enter your initials to confirm each statement.

I have informed the provider of any known allergies to drugs or other substances, or of any past reactions.

I have informed the provider of all current medications and supplements.

I understand I have the right to be informed of the procedure, alternatives, and the risks and benefits, and have had the opportunity to give informed consent.

I understand the procedure involves inserting a needle into a vein and infusing the prescribed solution, that alternatives include oral supplementation and lifestyle changes, and I understand the possible risks (bruising/discomfort at the site, warmth, and rarely phlebitis, drops in blood pressure or blood sugar, and extremely rarely severe allergic reaction).

My consent for nutrient infusion therapy is voluntary; I have not been offered any inducement, and I understand I may refuse treatment at any time.

I have read this consent form and understand the information contained in it, including the risks and benefits, and have had the opportunity to have all my questions answered. My signature affirms that I give my consent to IV nutrient therapy.

Patient signature (type full name) *

Date *

Release of medical information

I hereby authorize Infusion Wellness Center to disclose my medical records to EMS, my spouse, and my emergency contact. I also authorize Infusion Wellness Center to discuss my care and share my medical information for the purposes of monitoring, quality control, or safety concerns.

I authorize the release of medical information as described above. *

Patient signature (type full name) *

Date *