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CORE Cryotherpy & Wellness IV Consent Form

This questionnaire can be filled out using the form below and emailed to CORE Cryotherapy or you can download the PDF and print it and fill it out (it is about 6 pages long), everything is secure so nothing to worry about.

The only thing that can't be signed here is
Parental Consent Form.

Should you have any concerns or questions please call using the phone number at the top of the page.

NOTE: Please bring an ID with you

DOWNLOAD the CORE: IV Therapy Consent Form

Company

Full Name *

Phone Number: *

Date of Birth: *

Email Address *

Address: *

City: *

State *

Zip Code: *

Emergency Contact Name: *

Relationship: *

Phone: *

How did you hear about this Cryotherapy Location? *

Township Directory

Google

Facebook

Instagram

Twitter

Reference

Employee

Other

I authorize name to be prefilled below by an employee of Core Cryotherapy *

Yes No

I _________________________________________ hereby authorize the doctor(s) and nurses(s) at Core Cryotherapy to administer intravenous therapy to me. I understand that each physician independently contracts with the company, and is thus independently responsible for my medical care, and the company does not hold any responsibility for medical decisions made or treatments provided. I understand intravenous therapy is not a currently medically accepted procedure for treating any illness or concern and, thus, that it's used for this purpose may be considered by some insurance companies to be "medically unnecessary" or "experimental". I understand the procedure has some risks. Core Cryotherapy or his staff have explained to me verbally the short and long-term risk, which may include discomfort, bruising, infiltration, infection and pain at the injection site; temporary worsening of my current symptoms or headache, tachycardia (increased heart rate), syncope (fainting), visual difficulties, shortness of breath, joint pains, red eyes, itchy eyes, nasal congestion, numbness, gastrointestinal disturbances and a very rare but serious reaction called anaphylaxis. I also understand that other unforeseeable complications or side-effects could occur.

I understand the intravenous procedure involves inserting a needle into your vein and infusing over a determined period of time the prescribe nutrients (vitamins, minerals, amino acids) or chelating agents. The intravenous treatment
has benefits that are as follows: IV's or injectables are not affected by stomach or intestinal disease; total amount of infusion enters the blood stream and is available to the tissues; higher doses of nutrients can be given directly into the muscle or vein than by mouth thereby bypassing intestinal irritation when given by mouth; the vitamins and might increase the over-all well being; and nutrients are forced into cells by means of a high concentration gradient. The possible benefits include mitigation or improvement of my current symptoms, improvement of respiratory function, decreased skin reactions, increased stamina, improved metabolism, to decrease in frequency or severity of headaches, improved concentration, and others.

I have read and understand the risks and benefits above and have had the opportunity to have all of my questions answered. I understand that I have the right to consent or refuse any proposed treatment at any time prior to the administering of my IV. I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment and that IV therapy may not mitigate, alleviate, or cure my condition(s). The procedure set forth above has been adequately explained to me. I understand that I am free to withdraw my consent and to discontinue participation and their treatments at any time. I understand that I must give 24-hour notice of intent to cancel or reschedule my appointment. I understand that 1 will incur the full fee for treatment, regardless of the amount used due to wasted materials.

My signature below confirms that I have received all the information and explanation that I desire concerning the intravenous
therapy procedure. My signature below also confirms that I have given my consent to the IV therapy at Core Cryotherapy.

Patient Signature: *

Date Signed: *

Family Medical History

Depending on your answer a new field may open for more information - you or family - please indicate by placing a check mark in whichever answer applies to you.
Thanks

High Cholesterol *

Yes

Heart Disease, Arrhythmia *

Yes

Diabetes *

Yes

High Blood Pressue *

Yes

Asthma *

Yes

Tuberculosis *

Yes

Rheumatic Fever *

Yes

Thyroid Disease *

Yes

Liver Disease *

Yes

Stomach or Bowel Problems *

Yes

Gallbladder Problems *

Yes

AIDS (HIV) *

Yes

Currently Pregnant? *

Yes

Kidney Disease *

Yes

Glaucoma *

Yes

Allergies *

Yes

Breast Problems *

Yes

Blood Transfusion *

Yes

Cancer *

Yes

Birth Defects *

Yes

Inherited Diseases *

Yes

Psychiatric Illness *

Yes

Nervous Breakdown *

Yes

Constipation/Diarrhea *

Yes

Difficulty w/ Bowel Movements *

Yes

Lung Disease *

Yes

Anemia *

Yes

Pneumonia *

Yes

Arthritis *

Yes

GI Bleeding Disorder *

Yes

Gout *

Yes

Depression *

Yes

Chest Pain/Tightness *

Yes

Anxiety *

Yes

Pyelonephritis *

Yes

Stroke or TIA *

Yes

Swollen Ankles *

Yes

Osteoporosis *

Yes

Frequent Headaches *

Yes

Migraines *

Yes

Feet Swelling *

Yes

Seizure Disorder *

Yes

Insomnia *

Yes

Phlebitis *

Yes

No Known Medical Problems *

Yes

Please list any other medical problems not listed: *

Signature: *

Todays Date *

Present Status
Please answer the following questions as accurately as possible.

Depending on answer you may have an additional question to answer

Your Name: *

1. Have you ever had intravenous therapy before? *

Yes

2. Are you in good health at the present time to the best of your knowledge? *

Yes

3. Are you under a doctor's care at the present time? *

Yes

4. Are you allergic to any medications? *

Yes

5. Have you had any serious injuries in the last year? *

Yes

6. Have you had any surgeries in past year? *

Yes

7. Do you smoke cigarettes? *

Yes

8. Do you drink alcohol? *

Yes

9. Do you excercise regulary? *

Yes

10. How would you rate your diet? *

Good Fair Poor

11. How much water do you drink per day? *

0 - 3 8oz Glasses 4 - 7 8oz Glasses 8 - 11 8oz Glasses More

Please list any current medications you are taking: *

What is your main use of IV Therapy? (Check all the apply) *

Health and Wellness

StressRelief

Cosmetic/Beauty

Medical Condtition

Atheletic Performance

Rehydration

Increase Energy

Not a Bot

Disclaimer:

The services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. The material on this website is provided for informational purposes only and is not medical advice. Always consult your physician before beginning any treatment program.

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CORE Cryotherpy & Wellness IV Consent Form

Family Medical History

Present Status Please answer the following questions as accurately as possible.

Present Status
Please answer the following questions as accurately as possible.