IV Infusion Therapy Registration Form
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E-Mail Address
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example@example.com
Phone Number
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Address
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Street Address
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City
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Patient Medical History
Height (in)
*
Patient Weight (Ib)
*
Please list any drug allergies
Primary Care Physician and and Clinic Name:
Have you ever had (Please check all that apply)
*
Anemia
Anxiety
Asthma
Diabetes
Depression
Seizures
Fainting Spells
Heart Failure
High Blood Pressure
Digestive Problems
Ulcer Disease
Kidney Disease
Liver Disease
Thyroid Problems
Bleeding Disorders
Lung Disease
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Electrolyte imbalance
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Please list any Operations and Dates of Each
Please list your Current Medications
Include other comments regarding your Medical History
Please select your therapy package.
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Fountain of youth
$
225.00
Replenishes the body for noticeably healthier hair, skin and nails
Migraine Mender
$
225.00
Nutrient rich hydration to cure migraines.
Chelation Therapy
$
200.00
Improves blood flow by removing heavy metals from the body
Natural Defense
$
200.00
Boosts immune system and speeds up recovery from airborne illness
Rise & Shine
$
190.00
Reduces headache and fatigue caused by hangover.
The Executive
$
190.00
Promotes mental clarity and focus during the work day and beyond.
Myers Cocktail
$
175.00
Widely know nutrients to help a multitude of ailments.
Glutathione
$
160.00
Encourages cell revitalization and regeneration to promote younger, healthier looking skin.
Vitamin C
$
160.00
Boosts your immune system and promotes healthy skin.
Total
$
0.00
Vitamin C - Boost your immune system and promote healthy skin.
$145
The Executive -Promotes mental clarity and focus during work hours and beyond
$160
Other
Glutathione - Empowers cells, slows down aging and produces a brighter, healthier skin glow.
$160
Chelation Therapy- Improves blood flow by removing heavy metals in the bloodstream.
$200
Rise and Shine- Reduces headaches and stops feelings of fatigue or exhaustion after a hangover.
$175
Fountain of Youth: Replenishes the body for noticeably healthier skin, hair and nails.
$225
Natural Defense- Protects the body and speeds up recovery from an airborne illness such as a cold.
$200
Terms, Conditions & Consent for IV Hydration Therapy
Our hydration therapy is specifically designed to counteract symptoms of dehydration, fatigue, and the residual effects of
nutrients and H2O depletion.
We may offer diagnostic testing with these services, however you will have to schedule an appoitment for a medical consultation. Minneapolis Health Clinic reserves the right to refuse service
to any patients we deem are intoxicated unstable, or whose symptoms are not consistent with the above.
The
vast majority of our clients receiving our therapy feel greatly improved; however, every individual is different and there is
no guarantee that you will feel better after an infusion; nor does your improvement of symptoms exclude other coexisting
potential medical conditions.
This document is designed to serve as confirmation of informed consent for IV therapy as
by the qualified staff present at the current location.
I have informed the staff of any known allergies to drugs or other substances, or of any past reactions to anesthetics.
I have informed the staff of all current medications and supplements I am taking.
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 give my concerns.
I understand that t
he procedure involves inserting a needle into a vein and injecting the selected solution.
Risks of intravenous therapy include, but are not limited to: discomfort, bruising, and pain at the site of injection.
Other rare but possible side effects include but are not limited to: inflammation of the vein used for injection,
phlebitis, metabolic disturbances, and injury.
Nutrients are absorbed into the cells by means of a high concentration ingredient.
I understand the information provided on this form and agree to the terms and policies.
I have received all the information and explanation I desire concerning the procedure.
I authorize and consent to the performance of the procedures(s).
Signature
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