Client Information - Pediatric
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Past Medical History (list any and all conditions that you have been diagnosed with in the past):
Current Medications (Including all prescription, over-the-counter, herbs, vitamins, and supplements):
Allergies:
Part 1: |
Yes |
No |
Does your child take any diuretics or water pills, i.e. Lasix, Hydrochlorothiazide, Bumex, Spironolactone? |
|
|
Is your child taking steroids, i.e. Prednisone, Solumedrol, Decadron? |
|
|
Does your child have any history of congestive heart failure? |
|
|
Does your child have any history of kidney disease or renal failure/insufficiency? |
|
|
Does your child have any history of liver disease? |
|
|
Is your child on oxygen? |
|
|
Part 2: |
|
|
Is your child pregnant or breastfeeding? |
|
|
Does your child take any blood thinners, i.e. Pradaxa, Eliquis, Lovenox, Coumadin, Xarelto, Arixtra, Plavix, Heparin? |
|
|
Is your child on blood pressure medication? |
|
|
Does your child have any history of gastrointestinal bleeding or ulcer? |
|
|
Does your child have any history of QT prolongation on his/her EKG? |
|
|
Does your child currently have any medical concerns?
If YES, please explain
|
|
|
Informed Consent for IV Hydration Services
PARENT/GUARDIAN PLEASE CHECK EACH BELOW:
If you answered (“Yes”) to any of the above questions, it may be advised by the Medical Director that you not receive IV Fluids, and your child may be denied services.
I understand that participating in the intravenous (IV) hydration and vitamin administration services provided by Pure Drip IV Health & Wellness carries risks.
I have truthfully answered all questions regarding my child's medical history and have informed the staff about any and all prescription medications and/or over the counter drugs my child take, as well as any street or recreational drugs. I understand that failing to inform the staff about my child's medical issues and/or drug use can lead to serious complications.
I acknowledge that I am responsible for any medical care my child may have that is directly or indirectly related to the services provided by Pure Drip IV Health & Wellness. If my child seek medical treatment for any side effect or reaction, it will be at my own expense.
I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my child's voluntary participation in Pure Drip IV Health & Wellness services rests entirely with me to the extent that I fail to disclose my child's health condition(s), medications, or drug use in advance of the services provided.
I expressly represent and warrant to Pure Drip IV Health & Wellness that my child has never been diagnosed with or treated for any illnesses or conditions that may result in increased risk when participating in the services provided by Pure Drip IV Health & Wellness. I understand that Pure Drip IV Health & Wellness bears no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions.
I acknowledge that Pure Drip IV Health & Wellness relies upon information provided by me in assessing my child's ability to participate in the services provided.
I acknowledge that this procedure may be considered medically unnecessary, “unconventional,” and some treatments are not FDA approved. 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 my child is under treatment and in my child's overall health.
I acknowledge there is no guarantee that hydration therapy will temporarily or permanently cure or resolve my child's hangover, effects of altitude sickness, dehydration, or viral illness.
I acknowledge that hydration therapy is not a cure for heavy drinking. Excessive drinking can lead to alcohol poisoning and other serious medical problems.
IV hydration risks include the following:
Injury
Bleeding
Infection
Inflammation/Swelling
Infiltration of fluid
Misplacement of IV lines in the body
Air Embolism |
Allergic Reaction
Blood Clots
Fluid overload
Adverse interactions with medications
Nerve injury
Lightheadedness or fainting
Bruising or scarring from IV |
I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedures. I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that the staff to anticipate or explain all associated risks.
I waive any and all claims related to the services provided and agree to hold Pure Drip IV Health & Wellness harmless regarding any complications or consequences my child experiences during or following the service.
Pure Drip IV Health & Wellness therapies may be considered “performance enhancing.” If your child is a competitive athlete it is your responsibility to ensure that the materials administered are not on a banned list for your child's sport. We are able to provide you with the ingredients of any infusion you request.
Agreement to Arbitrate. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Colorado law and not by a lawsuit or resort to court process of any form, except as Colorado law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by client’s signature below and Pure Drip IV Health & Wellness acceptance of such signature, are voluntarily waiving their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.
All Claims Must be Arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, whether lying in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by any physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers affiliated with Pure Drip IV Health & Wellness (collectively herein referred to as “Provider”) to a client, including any spouse or heirs of the client and any children, whether born or unborn at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “client” herein shall mean both the mother and the mother’s expected child or children. This agreement does not waive the right of Provider to file in court to collect fees from client. Filing by Provider of any action in any court by the Provider to collect any fee from the client shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Provider, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
Procedures and Applicable Law
A notice or demand for arbitration must be communicated in writing by U .S. mail, postage prepaid, to all parties, describing the claim against Provider, the amount of damages sought, and the names, addresses and telephone numbers of the client, and (if applicable) his or her attorney. The parties shall thereafter select a mutually agreeable arbitrator to preside over the matter. Both parties agree the arbitration shall be governed pursuant to the Colorado Revised Uniform Arbitration Act, C.R.S. § 13-22-201, et. seq. The parties shall bear their own costs, fees and expenses, along with a pro rata share of the arbitrator’s fees and expenses.
MY SIGNATURE BELOW CONFIRMS THAT:
I have read, understand, and agree to the above arbitration agreement.
I am 18 years or older, of sound mind, and I authorize and consent to the use of hydration therapy on my child.
I am the parent and/or guardian of the above listed minor.
The procedure set forth above has been adequately explained to me by my attending medical professional.
I have received all of the information that I desire regarding hydration therapy. This document services as an informed consent for hydration therapy.
Client Signature
Date