Mobile IV Drips Delivered to You

Personalized IV hydration and vitamin therapy provided by licensed healthcare professionals APRN & RN, at home, work, gym, or hotel.
Hidratación intravenosa personalizada de vitaminas, brindada por profesionales de la salud con licencia (APRN y RN), en la comodidad de su hogar, trabajo, gimnasio u hotel.

Intravenous (IV) therapy involves the administration of fluids, vitamins, minerals, and/or medications directly into the bloodstream. The purpose of IV therapy at NutriVida Infusions is to support hydration, wellness, energy, recovery, immune function, and overall well-being.

I understand the following:

IV therapy may require needle insertion and carries risks including bruising, bleeding, pain, irritation, phlebitis, infiltration, infection, or allergic reactions.
Less common risks include dizziness, nausea, flushing, or fainting. Rare risks include anaphylaxis, vein damage, or air embolism.
I have disclosed all medications, supplements, allergies, and medical conditions to the provider
IV therapy is not a substitute for medical evaluation or emergency care, and results vary based on individual health status
I may stop treatment at any time.
I understand that providers may refuse treatment if it is unsafe or medically contraindicated.

By signing below, I voluntarily consent to receive IV therapy and acknowledge that I am responsible for informing my provider of any changes to my health.

Name

Last name

Date of birth.

Month

Day

Year

Phone

Emergency Contact / Phone

Medical History / Health Conditions

Please list all past and current medical conditions. Include diagnoses such as hypertension, diabetes, heart disease, kidney disease, asthma, anemia, autoimmune disorders, migraines, or any other relevant health condition.

Allergies

List all allergies, including medications, foods, vitamins, IV ingredients, latex, adhesives, or environmental allergies. If none, write "No known allergies."

Current Medications and Supplements

Please list all current medications, prescription drugs, over-the-counter medications, supplements, herbal products, and injections (for example: Mounjaro, Ozempic, hormonal therapy, antibiotics, steroids, NSAIDs, iron, birth control).

Consent & Acknowledgment

I confirm that I have read and understand the IV Therapy Consent Form.

I understand that IV Therapy is not a substitute for medical or emergency care.

I have disclosed all medical conditions, medications, supplements, and allergies.

I understand the potential risks and side effects of IV therapy, including bruising, pain, infection, infiltration, allergic reactions, or dizziness.

I understand that results vary and are not guaranteed.

I consent to receive IV therapy voluntarily and assume responsibility for my wellness decisions.

Patient Signature

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Date of Signature