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Medical History
Please list everything you are currently taking:
Medical History Continued
IV Nutrient Therapy
✓ Your completed Intravenous (IV) Infusion Therapy Intake Form
✓ A list of all prescription medications, OTC medications, vitamins/supplements that you take
✓ A copy of your most recent bloodwork is helpful
✓ Your signed Consent Form
✓ Your signed HIPAA Notice
✓ Make sure you are well hydrated prior to your visit. We suggest drinking 1-2 16 oz. bottles of water. Dehydration can make it difficult to insert an IV.
✓ Make sure you eat something prior to your visit. We suggest a high protein snack, such as nuts, seeds, a protein bar, cheese, yogurt or eggs. Low blood sugar can make you feel weak, lightheaded or dizzy.
During your first visit for IV Vitamin Therapy infusions:
During the first visit, Dr. Mendoza will discuss your main complaints and desired outcomes with you. Dr. Mendoza will review your medical & surgical history and any medications you are taking.
Based on this assessment, your Intravenous (IV) infusion will be customized to address your individual needs.
What to expect: The IVs used during you Intravenous (IV) infusion therapy are exactly the same that you would find in a hospital. Instead of a clinical experience though, our IV infusions are given in a peaceful spa setting and leave you feeling calm, relaxed, and refreshed.
All of our infusions last from 45-60 min. Our friendly and attentive staff will keep you calm, cared for, and comfortable during your infusion. Patients find the experience tranquil and healing. Patients leave feeling vibrant, energized, and refreshed.
Intravenous (IV) Nutrient Therapy Consent Form
I am aware that other unforeseeable complications could occur. I do not expect the physician(s) to anticipate and or explain all risk and possible complications.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.
My signature on this form affirms that I have given my consent to IV Nutrient Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.
My signature below confirms that: 1. I understand the information provided on this form and agree to the all statements made above. 2. Intravenous (IV) Nutrient Therapy has been adequately explained to me by my physician. 3. I have received all the information and explanation I desire concerning the procedure. 4. I authorize and consent to the performance of Intravenous (IV) Nutrient Therapy.
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928-440-1260