IV Therapy Screening and Consent

Form Instructions:

  • DO NOT USE THE BACK BUTTON
  • DO NOT REFRESH YOUR BROWSER
  • Once submitted this form cannot be revised or edited. Use the Addendum form if necessary.


Participant Information


Screening Questions


A "Yes" answer to any of these questions suggests the patient should not receive elective IV therapy. Additional explanation is required.

Please explain any YES answers below. It is suggested not to providing the service unless suitable clarification and/or medical director counsel is sought.

If providing services with a YES answer, please provide your reasoning for proceeding


Vitals

Pre-Infusion vitals

Vitals during Infusion

Post Infusion vitals


Treatment Provided


Other Treatments



Medical Professional