Patient Information, History and Consent Form

Date of Birth*
Patient Information
Legal Name*
First Middle Last
Phone*
Address*
Street Address City State ZIP Code
Email Address*
Medications & Allergies
Do you currently take any prescription medications?*
- Yes
- No
Medication List*
Please list all medications you are currently taking.
Do you have any known food, drug, or topical skin allergies?*
- Yes
- No
List of Allergies*
Are you allergic to methionine, inositol, choline, B vitamins, tape, or alcohol?*
- Yes
- No
Medical History
Past Medical History
Please check any boxes that apply to your medical history.
- Congestive Heart Failure
- Heart Disease
- Heart Murmur
- Pulmonary Embolism
- Bleeding Disorder
- Easy Bruising/Frequent Bleeding
- Blood Thinners
- Kidney Dysfunction or Renal Failure
- Liver Disease, Livery Dysfunction, Liver Cirrhosis or Hepatitis
- HIV/AIDS
- Fungal Infection
- Immunocompromised In any way
- Cancer or Chemotherapy
- Pregnant or Attempting To Get Pregnant
- Diabetes
- Hypertension or High Blood Pressure
- Neuropathy
Informed Consent For IV Hydration Services*
I understand that by signing this agreement, I am authorizing Key City Mobile IV, LLC to provide IV hydration services. The known risks have been explained, and I am fully aware of the risks involved in this medical procedure. I’m also aware that there are risks accompanying any medical procedure and there is no guarantee of the results of the services, as well as, freedom from potential complications. I acknowledge and agree to be responsible, at the time of the service, for the full amount of any charges for the IV hydration services provided. I have read, understand, and have a copy of this consent and accept all terms listed above. This document is intended to serve as confirmation of informed consent for IV hydration therapy and related services as provided by Key City Mobile IV, LLC. I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, and related services made available by Key City Mobile IV, LLC carries risks.

I expressly represent and warrant to Key City Mobile IV, LLC that I have never been diagnosed with nor treated for any diseases, illnesses, or conditions which may result in increased risk when I participate in services made available by Key City Mobile IV, LLC, and I am not choosing to participate with any expectations that Key City Mobile IV, LLC, will screen for, diagnose, monitor, or otherwise provide any care or treatment for such conditions. I expressly represent and warrant to Key City Mobile IV, LLC that I am not a user of illegal drugs and/or controlled substances and am not under the influence of the same or recovering from use of the same at the time of the provision of services. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regimen, programs and services rests entirely with me to the extent that I do not disclose my health conditions, medications or drug use in advance. I acknowledge and understand that Key City Mobile IV, LLC is relying upon the foregoing representations and warranties in providing IV hydration therapy and related services.

Possible risks include the following: injury, bleeding, infection, inflammation/swelling, bruising or scarring resulting from IV infiltration, extraction and extravasation. misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, light headedness or fainting. I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the risks intended from the services offered by Key City Mobile IV, LLC. I understand the nature of the services and that participating carries risks. I have been given an opportunity to ask questions, and all of my questions have been entered fully into my satisfaction. I agree to my assumption of all risks associated with my participation in the services.

Holdharmless Clause
The patient has received and understood the informed consent provided herein and the risk associated with the services to be provided. Patient, in consideration of receiving the services provided by Key City Mobile IV, LLC, does hereby release and hold Key City Mobile IV, LLC, its successors and assigns, employees and owners, harmless from any claim of injury or damage whatsoever caused by the services provided. This hold harmless shall be construed in the broadest possible manner and shall include but not be limited to all claims, known or unknown of any character resulting from the services provided.
I agree to these terms
Patient Signature*
Infusion Record & Nursing Assessment
Nice job! This following questions are for the Key City IV Team. Please return the mobile device to allow them to review your information.
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Picture of Government Issued Identification
Max. file size: 200 MB.
Verification*
- The patient has no contraindications for IV hydration therapy and their medical history has been obtained, consents have been reviewed, and signed by all parties.
- The medical history and current medications were reviewed, if any, and contraindications have been found.
Start Time*

: Hours

Minutes

AM/PM
Stop Time*

: Hours

Minutes

AM/PM
Temperature*
Respiratory Rate*
Blood Pressure*
Pulse*
Height*
Weight*
General Assessment*
No signs of Cardiopulmonary or physical distress. Mental Status: Alert and oriented to person place and time Neurological: No slurring of speech, moving all four extremities without difficulty or asymmetry on command, ambulates without difficulty or ataxia Cardiovascular: No rubs, murmurs, gallops, or irregularity on auscultation. Respiratory: Lungs clear to auscultation, without wheezing, rhonchi or crackles, no stridor and or swelling of upper airway, no jaundice (yellowing of skin or eyes).
No signs of Cardiopulmonary or physical distress. Mental Status: Alert and oriented to person place and time Neurological: No slurring of speech, moving all four extremities without difficulty or asymmetry on command, ambulates without difficulty or ataxia Cardiovascular: No rubs, murmurs, gallops, or irregularity on auscultation. Respiratory: Lungs clear to auscultation, without wheezing, rhonchi or crackles, no stridor and or swelling of upper airway, no jaundice (yellowing of skin or eyes).
Infusion Record
Infusion Record Checklist*
- Site preparation per protocol
- IV site secured per protocol
- Placement confirmed with blood return and easily flushes with good flow
Number of Attempts*
Gauge*
Site*
Protocols*
- B12 Injection
- Power Hour
- Cold & Flu
- Hangover Cure
- Hi-C
- All American
- Kardashian
- Pick Me Up
- Midterm Cram
- Project X
- The Myers
- MEGA Myers
- Stomach Bug Mini
- All American/Migraine Bag
- Prenatal Bag
Addons
- B Complex
- B-12
- Benadryl
- Biotin
- Caffeine
- Dextrose 5 Lactated Ringer’s
- Folic Acid
- Lactated Ringer’s
- Magnesium Sulfate
- Multivitamin
- Phenergan
- Reglan
- Toradol
- Thiamine
- Vitamin C
- Zofran
Narrative*
IV Completion*
- IV infusion completion, IV removal and final reassessment, improvement of initial symptom, vitals documented, site assessment with no swelling, bleeding, redness or tenderness. Patient stable without complication or incident.
Key City IV Technician Signature*
Key City IV Technician*
Phone
This field is for validation purposes and should be left unchanged.

Patient Information, History and Consent Form

Patient Information

Medications & Allergies

Medical History

Infusion Record & Nursing Assessment

Nice job! This following questions are for the Key City IV Team. Please return the mobile device to allow them to review your information.

Infusion Record