Consent Form

Please complete this form prior to your visit. This form only needs to be complete one time.

Name

First Name

Last Name

Date Of Birth

YYYY

Email Address

Phone

Allergies

Please list or mark none

Current Medications

Please list or mark none

Have you ever been diagnosed with

Kidney Disease

Heart Disease

Hepatitis

Cancer

Hypertension

HIV

Diabetes

None of the Above

I _________ am seeking the services of Vital H LLC of my own free will and give my consent to the administration of hydration IVs and any addition nutritional substances the healthcare team of Vital H and I agree on. I have the right to refuse any treatment proposed at any time and understand treatments are both naturopathic and conventional in nature. The risks involved are minimal to the procedures offered by Vital H LLC and no outcomes are guarunteed. I understand the risks of IM injections and IV therapy include discomfort,bruising and pain at the injection site, inflammation of the vein and allergic reaction. Temporary fluctuations in blood sugar and cytokine reactions are rare but possible. The procedures will be performed by an RN under the directions of Naturopathic Medical Doctor and a Certified Nurse Practitioner. All health information is confidential and Vital H LLC adheres to HIPPA guidelines. Vital H accepts private payment only and fees are due at time of service.

By typing your name below signifies your signature consent.