IV THERAPY PATIENT INTAKE FORM

Intravenous (IV) Infusion Therapy Consent Form
This document is intended to serve as informed consent for your Intravenous (IV) Infusion Therapy as ordered by the physician at TrueHeal Wellness.

(Initials)I have informed the nurse and/or physician of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or physician of my medical history.

(Initials)Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician's medical care.

(Initials)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 to give my informed consent.

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution. 2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. 3. Risks of intravenous therapy include but not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death. Benefits of intravenous therapy include: a)Injectables are not affected by stomach, or intestinal absorption problems. b) c)Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation. (Initials physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. (InitialsI understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

Total amount of infusion is available to the tissues.

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or

My signature below confirms that: 1. I understand the information provided on this form and agree with all statements made above. 2. Intravenous (IV) Infusion Therapy has been adequately explained to me by my nurse and/or physician/Nurse Practitioner. 3. I have received all the information and explanation I desire concerning the procedure. 4. I authorize and consent to the performance of Intravenous (IV) Infusion Therapy. I release Dr. Hawes Ruppert and Alka Sheladia, and all the medical staff at TrueHeal wellness from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.
Patient Name*

First NameLast Name
Patient's Date of Birth*

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Patient's Signature and Date*

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Date of Signature*

MonthDayYear
Registered Nurse or Physician's Name

First NameLast Name
Registered Nurse or Physician's Signature

Clear
Date of Signature

MonthDayYear

HIPAA NOTICE OF PRIVACY PRACTICE
(Effective April 15, 2021) At TrueHeal Wellness, Dr. Hawes Ruppert and Alkaben Sheladia, and his medical staff understand that health information about you is very personal and we are mandated by the Health Insurance Portability and Accountability Act (HIPAA) to protect your health information. We create a record of the care and services you receive from us, and this record helps to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by us, and informs you about the ways in which we may use and disclose information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

*Make sure that health information that identifies you is kept private

* Give you this Notice of our legal duties and privacy practices with respect to health information about you * Follow the terms of the Notice that is currently in effect

How we may use and disclose health information about you:

*For Payment *For Healthcare operations

* Health oversight activities Lawsuits and disputes

* For appointment reminders * As required by law

*To avert a serious threat to health and

* As required by the Military or Veterans and Workers Compensation * Coroners, health examiners and funeral directors

* Protective Services for the President and others

*Security Officials for Inmates

*National Security and Intelligence activities

Your rights regarding Health Information about you:

*Right to inspect and copy *Right to Amend

*Right to Accounting of Disclosures *Right to Request Restrictions

* Right to Request Confidential Communication

Your Medical Records: The original copy of your and/or electronic medical record is the property of TrueHeal Wellness. You may request a copy of your records to be transferred by completing a medical records release form. As allowed by NJ state law, there will be a fee for providing you with this service. We require 14 business days from the date of your request to prepare and send your records unless the records are for urgent or life threatening health issues. Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the current notice in our facility with the current effective date. Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact the administrator at the location where you were treated to file a complaint. For complete, detailed information regarding privacy laws, visit www.cms.gov/hipaa
Permission to Share your Health Information: We are required to follow certain federal guidelines and laws regarding the confidentiality of your personal health information. One of these prevents us from discussing anything in your medical file with anyone other than yourself or other medical personnel involved in your care. If you would like us to discuss lab results or other personal information with your significant other, family members, or any other individuals, please fill in their name and relationship to you in the section listed below.

Acknowledgement of Receipt of the TrueHeal Wellness HIPAA NOTICE OF PRIVACY PRACTICES: We request that you sign this form acknowledging you have received, read, and reviewed the TrueHeal Wellness HIPAA Notice of Privacy Practices. If the patient is a minor, the legal guardian is automatically appointed by law to provide/receive protected information on behalf of the patient. I will notify Dr. Hawes Ruppert or Alkaben Sheladia, and/or his staff of any changes or updates to this record. This acknowledgement will become part of your records.
Patient Name*

First NameLast Name
Patient and Signature*

Clear
Date of Signature

MonthDayYear

Intravenous (IV) Infusion Therapy Checklist
Checklist of What to Bring

Your completed Intravenous (IV) Infusion Therapy Intake FormA list of all prescription medications, OTC medications, vitamins/supplements that you takeA copy of your most recent blood work is helpfulYour signed Consent FormYour signed HIPPA NoticeMake sure you are well hydrated prior to your visit. We suggest drinking 1-2 16oz. bottles of water. Dehydration can make it difficult to insert an IV.Make sure you eat something prior to your visit. We suggest a high protein snack, such as nuts, seeds, a protein bar, cheese, yogurt or eggs. Low blood sugar can make you feel weak, light-headed or dizzy.
During your first visit for IV Vitamin Therapy infusions:

During the first visit, a Registered Nurse will discuss your main complaints and desired outcomes with you. The RN will review your medical & surgical history and any medications you are taking. Based on this assessment, your Intravenous (IV) infusion will be customized to address your individual needs. If you have any complex medical conditions, the physician/Nurse Practitioner at TrueHeal wellness may request you obtain blood work or further testing and/or your personal physician's approval prior to administering any IV infusions.

The IVs used during you Intravenous (IV) infusion therapy are exactly the same that you would find in a hospital. Instead of a clinical experience though, our IV infusions are given in a peaceful spa/home setting and leave you feeling calm, relaxed, and refreshed. Depending on your customized IV cocktail, the infusion can be finished in as little as 30-45 minutes. Our friendly and attentive staff will keep you calm, cared for, and comfortable during your infusion. Patients find the experience tranquil and healing. Patients leave feeling vibrant, energized, and refreshed.

Discharge Instructions for Intravenous (IV) Infusion Therapy
How to care for yourself after your IV Vitamin Therapy infusion:
- Apply pressure to site for 2 minutes after IV has been removed
- Keep Band-Aid in place for 1 hour
- Warm packs and elevating your arm can be used for any bruising at the site
- Cold packs can be used for pain relief and to decrease any swelling at the site
- Any swelling should be significantly reduced in 24 hours
- Post IV infusion symptoms are uncommon. Dehydration is the cause of most symptoms and concerns.
- We encourage you to drink at least 1-2 16oz. bottles of water after your IV infusion.
- If enough water is not consumed, you may experience any of the following symptoms: headaches, nausea, joint pain, blurred vision, cramping (GI and/or muscular), mental confusion or disorientation.
Most patients experience significant overall improvements:
- Better energy
- Better mental clarity
- Improved sleep
- Improvement of their complaints
- Overall feelings of well being
Patients commonly report one of two patterns after an IV Vitamin Therapy infusion:
- Patients generally feel better right away. Due to a busy lifestyle, many people are chronically dehydrated and deficient in vitamins and minerals causing them to not feel well. Once the patient is hydrated and the nutrients are replaced, their symptoms improve quickly.
- Patients sometimes feel tired or unwell. These patients are generally in the process of detoxifying. When toxins are pulled out of tissues, they re-enter the blood stream. They remain poisons, but they are now on their way OUT instead of on their way IN. Even when patients do not feel well at this stage, the process is one of healing and cleansing. After this period, an overall improvement in one’s sense of well-being is generally reported.
How often will I need IV Vitamin Therapy infusions?

The number and frequency of treatments will vary depending on certain factors.
- Condition(s) being treated
- Current health status of the patient
- Response of the patient to the treatments
A general estimate of the number of treatments needed is discussed during the first visit. As we go along, we will develop a more specific treatment plan. Most patients will require at least 5-10 treatments. Depending on the response, some patients will then go on to maintenance therapy with occasional treatments.

Call TrueHeal Wellness or your Primary Care Physician for:

Any symptoms you are not comfortable with. If any of the following are progressively worsening after your IV infusion:
- Significant swelling over the IV site
- Redness over the vein that is increasing in size
- Pain in the vein/arm that is not improving over an 8-12 hour period
Headache that does not resolve with increased hydration or over-the-counter pain relievers like aspirin, Acetaminophen or Ibuprofen.

If you feel like you are having a life threatening emergency, please call 911.
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PATIENT INTAKE FORM

Medical History

Intravenous (IV) Infusion Therapy Consent Form

HIPAA NOTICE OF PRIVACY PRACTICE

Intravenous (IV) Infusion Therapy Checklist

Discharge Instructions for Intravenous (IV) Infusion Therapy