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Primary Reason for Today's Visit

Medical History

Do you have any allergies?

Yes

Current Medications

Are you currently pregnant or breastfeeding?

Yes

Consent

I certify that the information I have provided is true and complete to the best of my knowledge. I understand that IV hydration therapy and vitamin injections are elective wellness services and are not intended to diagnose, treat, cure, or prevent any disease.

I understand there are potential risks associated with IV therapy and vitamin injections, including but not limited to bruising, discomfort, infection, allergic reactions, dizziness, and other unforeseen complications.

I have had the opportunity to ask questions regarding my treatment, and all of my questions have been answered to my satisfaction.

I voluntarily consent to receive IV hydration therapy and/or vitamin injections administered by the licensed healthcare provider or qualified medical professional.

HIPAA Acknowledgement I acknowledge that I have received or been given access to Laportia's Health & Beauty Bar's Notice of Privacy Practices and understand how my protected health information may be used.

I Agree

Photography Release (Optional) I authorize Laportia's Health & Beauty Bar to use photographs taken during my visit for marketing or educational purposes.

Yes

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