CONSENT AND DISCLAIMER FORM FOR IV THERAPY

This Consent and Disclaimer Form is intended to inform you, the patient, about the nature, purpose, risks, and benefits of Intravenous (IV) Therapy. By signing this form, you acknowledge and accept the terms outlined below and assume full responsibility for your decision to proceed with IV Therapy.

Patient Information

Telephone *

Clinical Assessment

Known Allergies

None Known

Current Medications / Supplements

Relevant Medical History

Kidney DiseaseLiver DiseaseHeart DiseaseDiabetesHypertensionAsthmaEpilepsyPrevious IV ReactionG6PD DeficiencyNone

Pregnancy / Breastfeeding

N/APregnantBreastfeeding

IV Therapy Details

Dosage *

100 ml250 ml500 ml1000 ml

Medication Administered *

Administration Record

Site

Left HandRight HandLeft ForearmRight ForearmACFOther

If Other, please specify

Observations (if clinically indicated)

Risks and Benefits

• IV therapy involves administration of fluids, vitamins, minerals and/or medicines directly into a vein.
• Potential benefits vary between individuals and are not guaranteed.
• Risks include pain, bruising, swelling, bleeding, infection, phlebitis, extravasation, allergic reactions, fainting, nausea and, rarely, serious complications.
• Alternative treatments have been explained where appropriate.

Patient Consent

I confirm I have provided an accurate medical history.I have had the opportunity to ask questions and have received satisfactory answers.I understand the potential benefits, risks and alternatives.I understand I may withdraw my consent at any time before or during treatment.I consent to emergency treatment if required due to an unexpected reaction.I voluntarily consent to proceed with IV therapy.

Adverse Reaction / Outcome

Reaction Observed

NoYes

Details

Action Taken

Patient Discharged

WellObservationGPA&E

Healthcare Professional Declaration

I confirm I have assessed the patient, confirmed they have capacity to consent, explained the procedure, benefits, risks and alternatives, answered all questions, and consider the treatment appropriate.

Name *

Job Title

GMC / NMC / HCPC Registration Number

Date *

Patient Signature

Date *

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