PATIENT REGISTRATION FORM Patient Details

  •  Health
  •  Heart Disease
  •  Diabetes
  •  High Blood Pressure
  •  Thyroid Problems
  •  Depression
  •  Yes
  •  No

PATIENT REGISTRATION FORM

Do you have, or have you had any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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PATIENT REGISTRATION FORM

I hereby authorize the following therapy: administration of intravenous fluid, multivitamins, and electrolytes.

This therapy is recommended for replacement of fluids, vitamins, and electrolytes to improve dehydration, vitamin deficiencies, electrolyte deficiencies, that can occur during extreme workouts, and after dehydration from alcohol intake. The hydration with intravenous fluids supplemented with a mixture of multivitamins can also complement the immune system.

The principal side effects that may accompany intravenous administration of nutrients include:
     -burning and stinging at the site of infusion
     -extravasation of fluid under the skin around the site of infusion
     -muscular spasms, weakness, or fatigue
     -allergic reactions (rare)
     -local thrombophlebitis ( rare)
     -local skin necrosis from extravasated fluid(rare)

This therapy may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment.

Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the doctors and other health professionals at HDR8- Hydration Therapy, LLC as is appropriate and necessary for my care.

I understand the benefits, risks, and options of hydration therapy from HDR8 – Hydration Therapy, LLC. I understand that I may suspend or terminate my treatment at anytime by informing my medical provider. I assume full liability for any adverse effects that may result from the non- negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

I hereby place myself under your care for intravenous hydration and vitamin supplementation, and agree to the above release. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of IV hydration and vitamin supplementation.

 

I hereby acknowledge that I understand that my Insurance coverage, including Medicare, may not pay for this Noncovered service, and that all services ancillary to this treatment may be also Non-covered services and Non-reimbursable. I agree to be responsible for payment at the time of service for all services, including Non-covered services.

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PATIENT REGISTRATION FORM NAD Therapy Consent

I, the undersigned, hereby give my voluntary consent to receive intravenous (IV) nicotinamide adenine dinucleotide (NAD) followed by optional Nutrient IV at HDR8 – Hydration Therapy.   The procedure is to be administered by the licensed staff of "insert clinic name" under the direct orders of Greg Jones, NMD.

NAD Therapy is a comprehensive amino acid, vitamin, and mineral treatment given for a variety of conditions. These amino acids, vitamins, and minerals are primarily administered through an IV.

 

I FULLY UNDERSTAND AND AM FULLY AWARE THAT:

  •  The desired effect, improvement, or relief of any condition for which NAD Therapy is to be applied may or may not be attained. Moreover, NAD Therapy does not preclude the need for other forms of therapy and I assume full responsibility for the treatment of my condition by other physicians practicing standard medicine, as may be deemed necessary for my well-being.
  •  There may be complications resulting from this procedure which could include but are not limited to infection, nausea, vomiting, diarrhea, pain and discomfort, weakness, fainting, micro-hemorrhages, ecchymosis, embolism, allergic reactions, shock, IV fluid infiltration, swelling, needle breakage and its retention, death, and even aggravation of current symptoms. Most patients report mild symptoms during the administration of NAD and the vitamin mixture that are transient.
  •  No assurances or guarantees have been made, nor can any be made concerning the results that may be obtained, but the physicians and nurses who will provide the treatment which I will undergo will perform their services, and take such precautions that are consistent with the standards of care that prevail for the same type of treatment provided to patients with conditions similar to mine.

By signing this consent form, I have not waived any of my legal rights or released this institution from liability for negligence. I also understand that I may revoke my consent at any time and withdraw from any further treatment without prejudice.

My signature below confirms that:
* I understand the information provided on this form and agree to the foregoing.
* The procedure(s) set forth above has been adequately explained to me by my nurse/physician.
* I have received all the information and explanation I desire concerning the procedure.
* I certify that I am not pregnant.
I certify that I am not intoxicated on alcohol or any illicit drugs.
* I authorize and consent to the performance of the procedure(s).

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