Location*

Date of Birth*

Patient Information

Legal Name*

First Middle Last

Phone*

Address*

Street Address City State ZIP Code

Email Address*

Medications & Allergies

Do you currently take any prescription medications?*

Yes
No

How would you like to provide your medication list?*

Manually Type
Upload A Photo

Medication List*

Please list all medications you are currently taking.

Medication List Images*

Drop files here or

Max. file size: 200 MB.

Do you have any known food, drug, or topical skin allergies?*

Yes
No

List of Allergies*

Are you allergic to methionine, inositol, choline, B vitamins, tape, or alcohol?*

Yes
No

Medical History

Past Medical History

Please check any boxes that apply to your medical history.

Informed Consent For IV Hydration Services*

I understand that by signing this agreement, I am authorizing Raider Rehab, LLC to provide IV hydration services. The known risks have been explained, and I am fully aware of the risks involved in this medical procedure. I’m also aware that there are risks accompanying any medical procedure and there is no guarantee of the results of the services, as well as, freedom from potential complications. I acknowledge and agree to be responsible, at the time of the service, for the full amount of any charges for the IV hydration services provided. I have read, understand, and have a copy of this consent and accept all terms listed above. This document is intended to serve as confirmation of informed consent for IV hydration therapy and related services as provided by Raider Rehab, LLC. I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, and related services made available by Raider Rehab, LLC carries risks.

I expressly represent and warrant to Raider Rehab, LLC that I have never been diagnosed with nor treated for any diseases, illnesses, or conditions which may result in increased risk when I participate in services made available by Raider Rehab, LLC, and I am not choosing to participate with any expectations that Raider Rehab, LLC, will screen for, diagnose, monitor, or otherwise provide any care or treatment for such conditions. I expressly represent and warrant to Raider Rehab, LLC that I am not a user of illegal drugs and/or controlled substances and am not under the influence of the same or recovering from use of the same at the time of the provision of services. I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regimen, programs and services rests entirely with me to the extent that I do not disclose my health conditions, medications or drug use in advance. I acknowledge and understand that Raider Rehab, LLC is relying upon the foregoing representations and warranties in providing IV hydration therapy and related services.

Possible risks include the following: injury, bleeding, infection, inflammation/swelling, bruising or scarring resulting from IV infiltration, extraction and extravasation. misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, light headedness or fainting. I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the risks intended from the services offered by Raider Rehab, LLC. I understand the nature of the services and that participating carries risks. I have been given an opportunity to ask questions, and all of my questions have been entered fully into my satisfaction. I agree to my assumption of all risks associated with my participation in the services.

Holdharmless Clause
The patient has received and understood the informed consent provided herein and the risk associated with the services to be provided. Patient, in consideration of receiving the services provided by Raider Rehab, does hereby release and hold Raider Rehab, its successors and assigns, employees and owners, harmless from any claim of injury or damage whatsoever caused by the services provided. This hold harmless shall be construed in the broadest possible manner and shall include but not be limited to all claims, known or unknown of any character resulting from the services provided.

I agree to these terms

Patient Signature*

Infusion Record & Nursing Assessment

Nice job! This following questions are for Raider Rehab Staff. Please return the iPad to your technician to allow them to review your information.

.

Picture of Government Issued Identification

Max. file size: 200 MB.

Verification*

The patient has no contraindications for IV hydration therapy and their medical history has been obtained, consents have been reviewed, and signed by all parties.
The medical history and current medications were reviewed, if any, and contraindications have been found.

Start Time*

:

Stop Time*

:

Temperature*

Respiratory Rate*

Blood Pressure*

Pulse*

Height*

Weight*

General Assessment*

No signs of Cardiopulmonary or physical distress. Mental Status: Alert and oriented to person place and time Neurological: No slurring of speech, moving all four extremities without difficulty or asymmetry on command, ambulates without difficulty or ataxia Cardiovascular: No rubs, murmurs, gallops, or irregularity on auscultation. Respiratory: Lungs clear to auscultation, without wheezing, rhonchi or crackles, no stridor and or swelling of upper airway, no jaundice (yelling of skin or eyes).

Infusion Record

Infusion Record Checklist*

Site preparation per protocol
IV site secured per protocol
Placement confirmed with blood return and easily flushes with good flow

Number of Attempts*

Gauge*

Site*

Protocols*

Addons

Narrative*

IV Completion*

IV infusion completion, IV removal and final reassessment, improvement of initial symptom, vitals documented, site assessment with no swelling, bleeding, redness or tenderness. Patient stable without complication or incident.

Raider Rehab Technician Signature*

Raider Rehab IV Technician*