Medical Consent Form
(IV, IM Therapy)
Please fill out this form below and our medical professionals will be contacting you shortly.
I hereby authorize Future Care Internal Medicine medical staff to administer Intravenous (“IV”) Infusion, Intramuscular (“IM”) Shots”). I acknowledge that these procedure(s) will be done with no sedation and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to IV, IM is my sole responsibility. I understand that my participation in all services provided by Future Care Internal Medicine is voluntary and I have the right to halt my service(s) at any time. A Provider may refuse service to me if I exhibit disruptive behavior and/or if I’m unable to provide informed consent under any circumstance including but not limited to inebriation. I understand the purpose of the specific IV/IM Therapy that I have selected. I know the practice of interventional and proactive medicine is not an exact science and I acknowledge that no guarantee can be made about the outcome of these service(s).
I understand that a provider may refuse service to me if I exhibit disruptive behavior and/or if I’m unable to provide informed consent under any circumstance including but not limited to inebriation.
With respect to IV/IM Therapy, I understand and agree that:
- There are general risks with any invasive procedure. These risks include, but are not limited to bleeding, bruising, and/or injury to surrounding tissues. These risks have been explained to me and I desire to continue.
- Adverse reactions may occur, and I attest to the best of my knowledge that I do not have a known allergy to any of the ingredients in the IV and/or IM that I have chosen. I also acknowledge that should an unforeseen reaction occur, Future Care Internal Medicine clinical staff will act accordingly to the protocols in place for such as event and that those actions may include discontinuing the IV infusion prior to its completion or seeking outside emergency services should my condition mandate that I will be transferred to a facility with a higher level of care. In exchange for an IV infusion and/or IM, I hereby waive, release and discharge Future Care Internal Medicine and its personnel from any liability from my receipt of this service. In consideration of being serviced by Future Care Internal Medicine, for any of its services I hereby waive any and all claims and damages for personal injury or death which may occur as a result of my participation. I understand and agree that:
1. The release is intended to discharge in advance Future Care Internal Medicine, its affiliates, officers, employees, and agents from and against all liability arising out of or connected in any way with my participation and/or receipt in these services;
2. I acknowledge that adverse reactions may occur, and I attest to the best of my knowledge that I have answered the health history form in full and accurately and I have not had alcohol in the last 2 hours. In exchange for any of these services I hereby indemnify and hold harmless Future Care Internal Medicine, its owners, employees, and agents from any loss, liability, damage, cost, or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities.
3. Participation may involve risk of serious injury, illness, disability, and/or death and may result not only as a result of my actions, negligence, or inaction but also from the action, negligence, or inaction of others, including their owners, officers, employees or agents, may result from the conditions of the facilities or areas where such activities are being conducted;
4. Knowing the risks involved and the contraindications related to which have been explained to me, I nevertheless choose voluntarily to request permission to participate and/or receive services;
5. I am in good health and have no physical condition which would preclude me from safely participating in such activities;
6. I understand and agree that this release is intended to be broad and inclusive as permitted under applicable state law and that if any portion of this waiver should be determined invalid, it is my intent that the remaining provisions shall continue in full force and effect. My signature below constitutes acknowledgment that I have read and agree to the above, and that a Future Care Internal Medicine provider and/or designee has satisfactorily explained IM, IV and that I have all the information that I desire.
I hereby give my authorization and consent to the implementation of IV and/or IM Therapy by Future Care Internal Medicine. Health Information Authorization
– I authorize Future Care Internal Medicine to use and/or disclose protected health information in accordance with the following:
- I give permission to Future Care Internal Medicine to use my address, phone numbers, and medical health records I provide to contact me with appointment reminders or notifications and to discuss any and all information about me and my services received, medical condition(s) and/or related topics to any Future Care Internal Medicine healthcare professionals and employees who assist those healthcare professionals.
- I am also aware and give permission that other customers and employees ofFuture Care Internal Medicine may overhear some of my protected health information during the course of my services. Therefore I release Future Care Internal Medicine from any and all state or federal statutes relating to patient privacy. Should I need to speak with the nurse in private I will request and subsequently be given a room for these conversations.
- I am also aware that I may ask to read Future Care Internal Medicine Privacy Notice regarding my rights of my health information. I acknowledge that I am signing as myself and/or as guardian on behalf of a child who is under 18 years of age:
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