Please select your options below, fill out medical history, and sign consent form.

Athletic Event *

Date you will be getting your IV or Injection *

First Name

Last Name

Date Of Birth

Sex at Birth

Male

Female

Patient Emergency Contact

Email

Street Address

City

State

Country

Country

Postal Code

Phone

Medical History

Are you pregnant?

Yes

No

Have you ever been told that you have an electrolyte imbalance or other abnormal labs?

Yes

No

Do you have any of the following conditions?
Select yes or no

Blood pressure problems (high or low)

Yes

No

Heart Problems

Yes

No

Stroke or “mini stroke"

Yes

No

Kidney Problems

Yes

No

Kidney Stones

Yes

No

Asthma

Yes

No

Optic nerve atrophy or Leber's Disease

Yes

No

Sickle Cell Anemia

Yes

No

G6PD Deficiency

Yes

No

Sarcoidosis

Yes

No

Parathyroid problems (high levels)

Yes

No

Are you a diabetic?

Yes

No

Drug Allergies

Over the counter medications including vitamins and other supplements:

List any other medical condition you have (not mentioned on previous page):

Prescription medications, strength dosage, condition being treated:

List all surgical procedures you have had:

Consent Form

Agree and sign to the following

I have informed PrimeHRT of any known allergies to medications, other substances and have provided a list of all current medications and supplements. I have fully informed PrimeHRT of my medical history.

Yes

No

I understand that I have the right to be informed of the procedure and the risks andbenefits. I am giving my informed consent.

Agree

Disagree

I understand that the procedure involves inserting a needle into a vein and injectionsolution with or without vitamins.

Agree

Disagree

I understand that there are risks of intravenous therapy that include but not limited to:* Occasionally: discomfort, bruising and pain at insertion site.* Rarely: inflammation of the vein phlebitis, metabolic disturbances, and injury.* Extremely rare: severe allergic reaction, anaphylaxis, infection, cardiac arrest ordeath.

Agree

Disagree

I understand the benefits include but not limited to: Injectables are not affected by stomach, or intestinal absorptions. Total amounts of infusions are available to the tissues.Nutrients are forced into cells by means of a high concentration gradient. Higher dosesof nutrients can be given than possibly by mouth without intestinal irritation.

Agree

Disagree

I am aware that other foreseeable complications could occur. I do not expect revive to anticipate and or explain all risk and possible complications, I rely on revive to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of all the procedures and have had the opportunity to have all my questions answered.

Agree

Disagree

My signature below confirms that: I understand the information provided on this form and agree to all the statements made above. Intravenous Infusion therapy has been adequately explained to me. I have received all the information and explanation I desire concerning the procedure. I authorize and give consent to the performance of Intravenous infusion therapy. I release PrimeHRT and all staff at PrimeHRT from all liabilities for any complications or damages associated with my Intravenous infusion therapy.

Agree

Disagree

Signature

Clear