Please bring this completed form to your first appointment. The details you provide will remain confidential.

Emergency Contact Information:

How much and how often do you consume the following?

Do any of the following apply presently or in the past? (please select)

Consent for Collection, Use and Disclosure of Personal Health Information

Your health privacy is a primary concern. The personal health information you disclose to Golden Days IV Hydration during your appointments will be handled in accordance with current privacy legislation and standards determined by the Maryland Department of Health. Personal health information includes identifiable information such as age, gender, family status and health history.

Golden Days IV Hydration Medical Providers and administrative staff will collect, use and disclose information about you for the following purposes:

To assess your health concerns;

To provide health care and advise you of treatment options;

To communicate with other health providers;

To establish and maintain contact with you;

To invoice for goods and services, process credit card payments; and

Administrative staff of Golden Days IV Hydration will have access to your record of personal health information and may come into contact with personal health information that is sent to or from the clinic. They will collect, use and disclose your personal health information so as to protect your privacy and the confidentiality of your

I have reviewed the above information and authorize Golden Days Providers and administrative staff of Golden Days IV Hydration to collect, use and disclose my personal health information as outlined above.

As a patient, I have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as to whether or not to undergo intravenous therapy with Golden Days IV Hydration.

Intravenous therapy is the administration of vitamins, minerals, amino acids, anti-oxidants, herbal extracts, and other natural medicines directly into the bloodstream through placement of a catheter or needle into a vein.

Benefits of intravenous therapy include (but are not limited to): ensured absorption of medicine(s) at therapeutic doses much higher than can be achieved orally (resulting in desired clinical outcomes more quickly); the absorption of intravenous medicines are not affected by gastrointestinal disease (which often compromises absorption); and rapid repletion of nutritional deficiencies (resulting in improved immune function, enhanced energy, pain reduction, hastened recovery time from injury, potential anti-cancer effects, detoxification support, etc

Potential risks and side effects of intravenous therapy include: pain, bruising and infection at the site of injection; slight bleeding once the catheter or needle is removed; allergic reaction (including anaphylaxis) to an administered medicine (if this were to occur, immediate therapeutic interventions would follow to stop such a reaction); a warming or burning sensation at the site of injection and/or along the vein in which medicine(s) are being administered (due to the nature of certain medicine(s) - this is normal, but can be modified if uncomfortable); hemolytic anemia/shock in patients with G6PD deficiency; general malaise and fatigue post-treatment; and dizziness, feeling faint, or changes in blood pressure and blood sugar during or following treatment (again, due to the nature of certain medicine(s) - be sure to inform the Golden Days Provider [or who is responsible for your care that day*] if any of these occur Other rare, but possible risks and side effects include: fever, nausea, edema, upset stomach, difficulty breathing, arrhythmias, cardiac arrest, death and other unlikely and unforeseeable complications.

I agree to follow the guidelines below (as discussed beforehand by Golden Days IV Hydration) prior to commencing therapy:ou

Staying well-hydrated by drinking adequate water the day of treatment Informing Provider of any allergies to any medicine (natural or otherwise), metal or other material Informing Provider if you are pregnant, have kidney failure, liver or heart disease Informing Provider of current or recent Methicillin Resitant (or similar) infectious disease Telling Provider of any fears you may be having regarding treatment so that they can be addressed

I voluntarily consent to intravenous therapy treatment. I can request further explanation and information of the procedure. I understand that the medicine(s) administered in intravenous therapy could potentially produce some side effects in certain sensitive individuals, as well as interact with certain medications or lab tests (to be discussed by NP Gumbs I wish to rely on NP Gumbs to exercise judgment in recommending the intravenous medicine(s) that she feels is in my best interest based on facts known at the time of treatment.

I understand that if I have been referred to Golden Days IV Hydration for intravenous therapy by another provider (naturopathic or medical), Golden Days Providers is not my naturopathic or primary care provider. I will continue my healthcare with my primary doctor (naturopathic or medical I also understand that if my primary doctor (naturopathic of medical) devises an intravenous formula for Golden Days to administer to me (provided they are qualified to do so), and I have a reaction (from mild to severe) to this administered formula that could have been prevented based on my primary doctor's (naturopathic or medical) knowledge of my health status, I absolve Golden Days IV Hydration from any wrongdoing.

Iunderstand that there have been no assurances or guarantees of successful treatment made to me. I understand that I am free to withdraw my consent and to discontinue participation in these treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment - without 24 hours notice, I understand that I will incur and pay a fee equal to the wasted materials plus 50% of the procedural fee involved in preparing the medicine(s) to be administered.

*Intravenous therapy (including compounding of substances for injection) is a controlled act that can be delegated by Shavonne M. Gumbs, CRNP to a qualified individual. As such, and with your consent, a Medical Laboratory Assistant/Technician extensively trained in intravenous therapy, will often be responsible for performing (and compounding substances for) intravenous therapy.

I HAVE READ AND UNDERSTAND THE ABOVE. Under the conditions indicated, I hereby place myself under the care of Golden Days IV Hydration for intravenous therapy.