IV Vitamin C Consent Form
Please complete this form to provide your informed consent for IV Vitamin C therapy. Your responses will help ensure your safety and the appropriateness of this treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any known allergies?
*
No
Yes (please specify below)
If yes, please list your allergies
Are you currently taking any medications or supplements?
*
No
Yes (please specify below)
If yes, please list your current medications or supplements
Do you have a history of kidney stones, heart disease, or any chronic illness?
*
History of kidney stones
Heart disease
Other chronic illness (please specify below)
None of the above
If other chronic illness, please specify
By signing below, I confirm that I have read, understood, and agree to receive IV Vitamin C therapy. I acknowledge that I have had the opportunity to ask questions and that all my questions have been answered to my satisfaction.
*
Submit Consent
Submit Consent
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