Consent Form

Consent For Treatment & Medical History

Full Name of Patient: *Date of Birth:Email Address:Gender: *Phone Number: *Address:Check any medical conditions that apply to you: *N/AAsthmaHigh Blood PressureHeart ConditionsLunch ConditionsCancerOtherNeurological ConditionsSeizuresDiabetesLiver ConditionsKidney Conditionsplease list any other medical conditions if not listed aboveAre you currently taking any medication?: *YesNoIf Yes, please list allergy and reaction:Type of IV:Date of Service:Time Frame (more options the better)

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

1. I understand the information provided on this form and agree to all statements made above.
2. Intravenous infusion therapy has been adequately explained to me by Registered Nurse/ or physician and understand the risks and benefits involved.
3. I have received all the information and explanation I desire concerning the procedure.
4. I authorize RevIVe Drip Haus, and all medical staff from all liabilities for any complicationsordamages associated with my IV infusion therapy.

Let's Approach Wellness Together

Join a camp

REVIVE DRIP Haus

Helping You Achieve Wellness

About
IV MENU
Consent Form
Contact

Join our newsletter

Join our newsletter to stay up to date on news, events, and special deals.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.