Free IV Therapy Consent Form Template

Obtaining informed consent for IV therapy can feel daunting, but this template simplifies the process for you. Designed for healthcare professionals, this IV therapy consent form ensures that patients understand the treatment and its potential risks, leading to improved safety and trust. Effectively communicate treatment details, gather patient signatures, and maintain compliance with regulations, all while keeping the process straightforward. Explore how this customizable template can enhance your practice and patient experience.

When to use this form

Use this consent before any vitamin infusion, hydration drip, NAD+, or medication-based IV service, whether in a clinic, med spa, mobile visit, or event. It helps you confirm the patient understands benefits, risks, and alternatives, and it collects medical history, allergies, and signatures in one place. RNs, NPs, and practice owners use it to standardize disclosures, screen out contraindications, and reduce liability. If you also deliver wellness or counseling services, align your language with a Therapy informed consent form. Multidisciplinary teams can keep policies consistent across departments using a Professional counseling informed consent form.

Must Ask IV Therapy Consent Questions

Do you understand the purpose, expected benefits, material risks, and alternatives, and do you consent to treatment today?
This confirms informed consent and documents that the patient weighed options before proceeding. Clinics that also provide counseling can mirror language from a Psychotherapy informed consent form to keep disclosures consistent.
What allergies or sensitivities do you have (medications, vitamins, latex, adhesive, alcohol swabs, or IV solutions)?
Identifying allergens prevents reactions and guides product selection and site prep. You can choose compatible catheters, antiseptics, and diluents before starting the drip.
What medical conditions do you have (heart, kidney, or liver disease), and are you pregnant or breastfeeding?
Underlying conditions change fluid tolerance, infection risk, and electrolyte handling. This helps you adjust dose and rate or defer treatment when unsafe.
Which medications and supplements do you take, including blood thinners, diuretics, steroids, or herbal products?
Many agents interact with vitamins or increase bleeding and bruising risk at the IV site. A complete list informs infusion composition, monitoring, and aftercare.
Have you had adverse reactions to injections or infusions before (fainting, phlebitis, infection), and who is your emergency contact?
Past events predict complications and help you plan observation and comfort measures. An emergency contact speeds communication if symptoms escalate during or after the drip.

More Forms

Question		Response
Full name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Mobile phone		555 555 5555
Email address		[email protected]
Emergency contact full name		John Smith
Emergency contact relationship		This is a test
Emergency contact phone		555 555 5555
Do you have any known allergies to medications, foods, latex, or adhesives?		Unsure
Please list any allergies and reactions		This is a test
Are you currently taking any prescription, over-the-counter, or herbal medications or supplements?		Yes
If yes, please list medication names and doses		This is a test
Do you take any blood thinners or anticoagulants?		Unsure
Do you have any of the following conditions? (Select all that apply)		Liver disease
Have you ever had a reaction or complication from an IV, injection, or medication?		Unsure
If yes, please describe the reaction or complication		This is a test
Are you currently pregnant or breastfeeding?		Not applicable
Have you eaten and hydrated today?		No
Primary care or treating clinician name (optional)		This is a test
Are you under the care of a clinician for any ongoing condition?		Yes
Date of treatment		2025-10-15T00:00:00.000Z
IV therapy requested or ordered		This is a test
If other goals, please specify		This is a test
Your goals for this IV therapy (select all that apply)		Nausea relief
I understand the potential risks of IV therapy including bruising, pain, redness, infiltration/extravasation, infection, allergic reaction, phlebitis, fluid overload, nerve injury, and scarring.		4
I understand that possible side effects such as taste changes, flushing, dizziness, nausea, or headache may occur.		2
I understand that IV therapy may not treat or cure medical conditions and that results are not guaranteed.		2
I understand the alternatives, including oral supplementation or declining treatment, and that I may withdraw consent at any time.		1
I agree to follow aftercare instructions and to report any concerning symptoms promptly.		3
I consent to receive venipuncture and IV infusion as ordered.		No, I do not consent
I consent to be contacted about appointments and follow-up by (select all that apply)		Email
I consent to photographs for clinical documentation.		Yes
I consent to the use of de-identified photos for marketing.		No
I understand that I am financially responsible for services received.		Yes
Full name of patient or legal representative		John Smith
Relationship to patient		Self
If other relationship, please specify		This is a test
Date		2025-10-15T00:00:00.000Z
By entering my name, I certify that I have read and understand this consent and authorize the IV therapy indicated.		False

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IV Therapy Consent Form Template

Streamline patient consent with ease and compliance

When to use this form

Must Ask IV Therapy Consent Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

IV Therapy Consent Form Template

Streamline patient consent with ease and compliance

When to use this form

Must Ask IV Therapy Consent Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results