Medical History

Allergies

Medications

List all current medications, including dosage and frequency:

Family Medical History

Lifestyle

Social History

Review of Systems

Please check any symptoms you are currently experiencing or have experienced in the past:

Consent for Treatment:

Consent for Treatment:

I, ______________hereby authorize the healthcare provider at Wellness & IV Lounge to provide approved IV services. I understand that I am responsible for all charges incurred for services rendered.

Signature: _______________________________ Date: ______________

APPROVAL STATEMENT: 

After a comprehensive review of the patient's current and past medical history, medications, and overall physical health profile, I have determined the patient is cleared to proceed with the recommended treatment by the referring organization. Understanding that a patient's medical history and medications may change over time, updates and evaluations by the providers at the attending organization may be necessary for any current and future treatments. It is the responsibility of the patient to inform, and the treating clinicians to update, any recent changes in medical history to ensure the safety of the ongoing medical treatment plan. Registered nurses/clinicians at the referring organization must obtain authorization from an MD before treatment if there are changes in medical conditions, new medications, or concerns about any increased risk of complications based on the information provided above.