Mobile IV Consent Form

Streamline your IV rehydration process with our convenient mobile consent form. Easily request and obtain patient consent for intravenous hydration therapy anytime, anywhere.

Name(Required)
MM slash DD slash YYYY
I hereby grant permission to capture photographs of my likeness by The Struggle Bus for documentation and archival purposes.
I consent to the recording of my image on video by The Struggle Bus for documentation and archival purposes.
I authorize The Struggle Bus to share and use photographs and videos featuring me in their materials for educational and promotional purposes.

I consent to the insertion of a peripheral intravenous catheter and to the infusion of fluids, vitamins, mineral and/or compounded cofactor, and/or medications. I agree and acknowledge that no promises or guarantees were made regarding the efficacy of the infusion. Further, I acknowledge that statements regarding vitamin and mineral infusions have not been evaluated by the FDA and that the infusion of such has no diagnostic value nor is the infusion a substitute, cure, therapy, or treatment for any disease or condition.(Required)
If at any time, a determination is made that the procedure or infusion is outside of the conditions of safety, it may be discontinued. I understand the benefits of IV infusions may be limited if I am an active smoker, live a sedentary lifestyle, and/or have a diet that contains an excess of calories and/or a deficiency of nutrients.(Required)

Risks

I acknowledge that I am aware of the risks inherent in peripheral vascular catheterization and infusion that include but are not limited to: local irritation, pain, infection, phlebitis (irritation of the vein), venous thrombosis, shortness of breath, allergic reaction, fluid volume overload, medication interactions, and death. Despite these risks (and others) I consent to the procedure. I may withdraw my consent at any time.(Required)

Payment

Payment is due prior to service. There has been no representation that this procedure is covered under any insurance plan or that you can/should seek such reimbursement.
I agree to pay the full cost of the service regardless if the infusion cancelled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself. I understand that I am responsible for the full cost of the procedure and agree to pay. THE PROCEDURE(S) AND THIS CONSENT FORM HAVE BEEN ADEQUATELY EXPLAINED TO ME.(Required)
I certify that I am not pregnant.(Required)
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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