Complete the Consent Form

Please click below to complete the medical consent to treatment form. We will email you a copy of your consent information.

Treatment Consent Form

This document is intended to serve as patient’s informed consent for medical treatment. Please check each section to give us permission to treat you.

Please note that your information is saved on our server as you enter it.

Medical History(Required)

I have provided my medical history to Hydrafuse

I have informed my healthcare professional of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed my healthcare professional of my medical history.

Disclaimer(Required)

I understand these infusions have not been evaulated by the FDA.

I understand and acknowledge that: intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease; and IV infusions are not a substitute for my physician’s medical care.

Your Right to Be Informed about Your Procedure(Required)

I understand I have the right to be informed about the procedure and its risks and benefits.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

Behaviors and Conditions That Can Reduce the Efficacy of IV Infusion Therapy(Required)

I understand that cigarette smoking, caffeine consumption, poor diet and heavy metal toxicity may hinder the effectiveness of the infusion treatment I have selected.

I understand that the following may reduce the efficacy of IV Infusion Therapy: cigarette smoking; caffeine consumptions (increases vitamin C excretion); poor die (processed foods, high sugar intake, nutrient deficient diets); heavy metal toxicity

Consent to Undergo IV Infusion Therapy(Required)

I understand that this procedure involves inserting a needle into a vein and injecting the prescribed solution.

I understand the procedure involves inserting a needle into a vein and injecting the prescribed solution. I am also aware there are alternatives to intravenous therapy, such as oral supplementation and/or dietary and lifestyle changes.

Acknowledgments of the Risks of Intravenous Therapy(Required)

I understand the possible side effects of undergoing IV therapy.

a. Occasionally: Discomfort, bruising and pain at the site of injection, a fall in blood pressure (staff will stop the infusion and provide IV fluids to help it return to normal).
b. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
c. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
d. Long-term adverse consequences of these therapies may be possible but are unknown at this time. IV therapy is not FDA-approved to treat or prevent any illness or disease.

Awareness of Unforeseen Complications(Required)

I understand the risks and benefits of the procedure and have had the opportunity to have my questions answered.

I am aware that other unforeseeable complications could occur. I do not expect my Healthcare Professional to anticipate and or explain all risks and possible complications. I rely on my healthcare professional to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have my questions answered.

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