CLIENT CONSENT FORM

Important Message to our Clients & Visitors:

The safety of our clients and our team here at Sunshine Coast Infusion Therapies is our first priority, if you are showing flu-like symptoms or have recently returned from overseas travel (or have been in contact with a returning overseas traveller), we ask that you avoid visiting our clinic until after a 14 day isolation period. If you are unsure, please contact us prior to booking an appointment.

Thanks,

Marie & John

CLIENT CONSENT FORM

SUNSHINE COAST INFUSION THERAPIES

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If you are a first-time customer please complete the CLIENT CONSENT FORM below and submit – if we need to discuss this further with you we will give you a call or email you.

Alternatively, you can skip this and BOOK NOW, you will receive an email where you can submit this later. Or you can print it and drop it in or fill it in at our clinic.

CLIENT CONSENT FORMS are stored on file and you can have this removed at any time by calling our team on 07 53379191 or 0432 935 150.

SUBMIT THE ONLINE CONSENT FORM THEN BOOK

DO THIS LATER & MAKE A BOOKING NOW

PRINT THE CLIENT CONSENT FORM

ALL TEAM BOOKINGS : For all bookings, including teams, we request ALL clients using our services submit a completed CLIENT CONSENT FORM. Contact our team for more information on Team Bookings.

PLEASE READ CAREFULLY & COMPLETE ALL APPLICABLE FIELDS

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Intravenous Infusion Therapies

This document is to inform you of the procedures to be performed and the risks associated with the treatment.This will then enable you to make an informed decision whether to go ahead with your treatment.

What is Intravenous Nutritional Therapy

This is where a small needle (Cannula) is introduced into the client’s vein with a customised infusion attached. This is then slowly administered efficiently with vitamins, minerals, amino acids and other natural substances directly into the bloodstream bypassing the client’s digestive system.

By direct delivery into the bloodstream this allows the body to achieve optimal levels. These increased levels can provide an immediate therapeutic response and may correct deficiencies.

A wide range of factors, both in one’s physiology and food supply, can lead to poor absorption of nutrients and depletion of the body’s essential vitamins, minerals. Over time, we experience varying levels of fatigue, sub-optimal performance, weight gain, to more serious conditions and illnesses.

Benefits of Intravenous Infusion Therapy

Receive 100% of the nutrients and is not affected by the stomach, intestinal disease or malabsorption.
Directly available to the cells/tissues
Nutrients are pushed into the cells by a means of a higher concentration gradient.
Increased doses are able to be infused than orally, as will not produce intestinal irritation.

Proposed Treatment

Prior to the treatment you will have a consultation with our treating professionals and a nutritional recommendation will be discussed. We will not diagnose treat or cure any specific diseases and the nutritional recommendations we make do not constitute treatment for any disease or affliction.

The purpose of your treatment may benifit :

Improve your general of wellbeing
Improve your overall nutritional status
Aid in the slowing down of the ageing process
Improve your metabolism
Aid possible remission reduction of pain where present

Please understand that all nutrient infusions given at Sunshine Coast Infusion Therapies are considered investigational/experimental. These infusions are not considered usual standard of care and are not billable to Health Insurance.

ALL FIRST TIME CLIENTS MUST FILL IN THIS FORM & SUBMIT PRIOR TO TREATMENTS

FULL NAME (required)

D.O.B (required)

PHONE (required)

YOUR EMAIL (required)

EMERGENCY CONTACT NAME(required)

EMERGENCY CONTACT PHONE (required)

HOW DID YOU HEAR ABOUT US (required)

WHAT DO YOU HOPE TO ACHIEVE WITH OUR SERVICES (required)

...

MEDICAL INFORMATION - Please list any medications you are currently taking, the conditions associated with it and the respective doses.

MEDICATIONS & CONDITIONS (required)

LIST ALL ALLERGIES YOU HAVE TO DRUGS, FOOD OR OTHER ITEMS

ARE YOU CURRENTLY UNDER MEDICAL CARE FOR ANY REASON? IF YES, PLEASE EXPLAIN (required)
YESNO

IF YES, PLEASE EXPLAIN

...

HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

ASTHMA AND/OR EMPHYSEMA (required)
YESNO

IF YES, PLEASE EXPLAIN

OBSTRUCTIVE SLEEP APNOEA (required)
YESNO

HOME OXYGEN (required)
YESNO

IF YES, PLEASE EXPLAIN

UNCONTROLLED HIGH BLOOD PRESSURE (required)
YESNO

CHEST PAIN, ANGINA, HEART ATTACK (required)
YESNO

IF YES, PLEASE EXPLAIN

PACEMAKER or DEFIBRILLATOR (required)
YESNO

HEART DISEASE, ARTIFICIAL VALVES OR STENTS IN HEART (required)
YESNO

DIABETES - CONTROLLED OR UNCONTROLLED (required)
YESNO

CIRRHOSIS or LIVER DISEASE (required)
YESNO

SUFFERED A STROKE? (required)
YESNO

IF YES, PLEASE EXPLAIN

CHRONIC KIDNEY DISEASE (required)
YESNO

BLOOD THINNING MEDICATION (required)
YESNO

IF YES, PLEASE NOTE THE MEDICATION YOU ARE/WHERE TAKING

HEPATITIS (required)
YESNO

FEVER or COLD (required)
YESNO

HIV (required)
YESNO

HAD SURGERY WHERE LYMPH NODES HAVE BEEN REMOVED FROM UNDER YOUR ARM AREAS? (required)
YESNO

IF YES, WHAT ARMS?
RIGHTLEFTBOTH

ARE YOU TO HAVE CHEMOTHERAPY SOON? (required)
YESNO

HAVE YOU RECENTLY HAD CHEMOTHERAPY? (required)
YESNO

CAN YOU WALK ONE FLIGHT OF STAIRS WITHOUT RESTING? (required)
YESNO

DO YOU HAVE ANY ILLNESS OR PROBLEMS INCLUDING CHRONIC PAIN THAT WE NEED TO KNOW ABOUT? (required)
YESNO

IF YES, PLEASE EXPLAIN WHAT AND WHEN

DO YOU HAVE A FEAR OF NEEDLES? (required)
YESNO

DO YOU HAVE A PHOBIA OF BLOOD? (required)
YESNO

DO YOU HAVE A PAST EXPERIENCE IN FAINTING OR DIZZINESS? (required)
YESNO

IF YES, WHAT ARE THE POTENTIAL CAUSES?

IS THERE ANY LIMITATION IN THE MOVEMENT OF YOUR NECK OR JAW? YOU SHOULD BE ABLE TO OPEN YOUR MOUTH AT LEAST TWO FINGERS IN WIDTH AND BE ABLE TO TILT YOUR HEAD BACK TO LOOK STRAIGHT UP (required)
YESNO

DO YOU HAVE ANY OTHER MEDICAL ISSUES, ALLERGIES OR SYMPTOMS THAT WE SHOULD KNOW ABOUT?

...

LIMITATIONS

I understand that that an initial series of treatments could be recommended and that these treatments may extend over a number of weeks or months. I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet and nutritional supplementation). I understand that as with any other treatment, I may not receive benefit because they do not occur predictably with every patient and in a small percentage of patients they may not occur at all.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

RISKS & COMPLICATIONS

I understand that intravenous nutrition therapy using Vitamins, Minerals, Amino Acids and other nutrients has been widely used in Europe and the USA for many years. However, with all medications or drugs, nutritional supplements may exhibit some side effects in certain individuals.

Adverse effects from Intravenous Nutrition Therapy include but are not limited to:

- Discomfort, bruising and pain at the site of injection.
- Inflammation, infiltration or infection at the site of the injection.
- There is a potential to feel a warm sensation throughout your body, which is a normal feeling when magnesium is used in your treatment.If however you are in any discomfort or distress, please tell the professional immediately.
- Possible fall in blood pressure, which can be related to magnesium in the IV. The professional will be presented able to help you by stopping the infusion/or providing some extra IV fluid to bring the blood pressure to normal.
- Allergic reaction or Anaphylaxis to a nutrient, a needle, or other supplies used.
- There is potential for dizziness, feeling fainter changes in blood pressure and blood glucose levels during or following your treatment due to some nutrients. Inform the professional immediately if you feel any of these systems.
- Other rare, but possible side effects include: fever, nausea, oedema, upset stomach, difficulty breathing, arrhythmia’s and stroke.
- As with any treatment there is also a possibility of other unforeseen adverse effects.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

This is strictly a voluntary procedure. No treatment is necessary or required. Other alternative treatments, which vary in sensitivity, effects and duration, include oral supplementation and/or dietary and lifestyle changes.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

I, the Client, represent that I am at least 18 years of age, have read and understand this release form, and am competent to exercise this agreement.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE
If 'AGREE' is selected and the client is younger than 18yrs old, a guardian MUST fill in the following step.

The Client is under 18 years of age or under the supervision of a Guardian. I have read and understood this release form. I, am Guardian sign this form as confirmation that I am competent to execute this agreement on behalf of the client.

PLEASE CHECK AGREE OR DO NOT AGREE IF UNDER 18 YEARS OLD
AGREEI DO NOT AGREE

PLEASE TYPE YOUR FULL NAME (BY GUARDIAN) (required)

DATE (BY GUARDIAN) (required)

...

CONSENT

I certify that :

- I have read and fully understood the above paragraphs and discussed the risks, benefits and alternatives to this treatment
- I have had sufficient opportunity for discussion and to ask questions.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

I have had time to consider the treatment :

- I believe I have adequate knowledge to request this treatment and consent to the proposed treatment
- I accept the risks and complications associated with the procedure and there are no material circumstances preventing me from having this treatment
- I have provided an accurate medical history and I have not withheld any information
- I am of the opinion that my request for treatment is not for medical reasons and the personal psychological features that are associated with my request
- I have expressed my thought and feelings to the treating professional and consent to the treatment for the purpose of restoring and maintaining the health of my skin and body and my psychological wellbeing

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

PLEASE TYPE YOUR FULL NAME (required)

DATE (required)

PLEASE READ CAREFULLY & COMPLETE ALL APPLICABLE FIELDS

_

FULL NAME (required)

D.O.B (required)

PHONE (required)

YOUR EMAIL (required)

EMERGENCY CONTACT NAME(required)

EMERGENCY CONTACT PHONE (required)

HOW DID YOU HEAR ABOUT US (required)

WHAT DO YOU HOPE TO ACHIEVE WITH OUR SERVICES (required)

...

MEDICAL INFORMATION - Please list any medications you are currently taking, the conditions associated with it and the respective doses.

MEDICATIONS & CONDITIONS (required)

LIST ALL ALLERGIES YOU HAVE TO DRUGS, FOOD OR OTHER ITEMS

ARE YOU CURRENTLY UNDER MEDICAL CARE FOR ANY REASON? IF YES, PLEASE EXPLAIN (required)
YESNO

IF YES, PLEASE EXPLAIN

...

HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

ASTHMA AND/OR EMPHYSEMA (required)
YESNO

IF YES, PLEASE EXPLAIN

OBSTRUCTIVE SLEEP APNOEA (required)
YESNO

HOME OXYGEN (required)
YESNO

IF YES, PLEASE EXPLAIN

UNCONTROLLED HIGH BLOOD PRESSURE (required)
YESNO

CHEST PAIN, ANGINA, HEART ATTACK (required)
YESNO

IF YES, PLEASE EXPLAIN

PACEMAKER or DEFIBRILLATOR (required)
YESNO

HEART DISEASE, ARTIFICIAL VALVES OR STENTS IN HEART (required)
YESNO

DIABETES - CONTROLLED OR UNCONTROLLED (required)
YESNO

CIRRHOSIS or LIVER DISEASE (required)
YESNO

SUFFERED A STROKE? (required)
YESNO

IF YES, PLEASE EXPLAIN

CHRONIC KIDNEY DISEASE (required)
YESNO

BLOOD THINNING MEDICATION (required)
YESNO

IF YES, PLEASE NOTE THE MEDICATION YOU ARE/WHERE TAKING

HEPATITIS (required)
YESNO

FEVER or COLD (required)
YESNO

HIV (required)
YESNO

HAD SURGERY WHERE LYMPH NODES HAVE BEEN REMOVED FROM UNDER YOUR ARM AREAS? (required)
YESNO

IF YES, WHAT ARMS?
RIGHTLEFTBOTH

ARE YOU TO HAVE CHEMOTHERAPY SOON? (required)
YESNO

HAVE YOU RECENTLY HAD CHEMOTHERAPY? (required)
YESNO

CAN YOU WALK ONE FLIGHT OF STAIRS WITHOUT RESTING? (required)
YESNO

DO YOU HAVE ANY ILLNESS OR PROBLEMS INCLUDING CHRONIC PAIN THAT WE NEED TO KNOW ABOUT? (required)
YESNO

IF YES, PLEASE EXPLAIN WHAT AND WHEN

DO YOU HAVE A FEAR OF NEEDLES? (required)
YESNO

DO YOU HAVE A PHOBIA OF BLOOD? (required)
YESNO

DO YOU HAVE A PAST EXPERIENCE IN FAINTING OR DIZZINESS? (required)
YESNO

IF YES, WHAT ARE THE POTENTIAL CAUSES?

DO YOU HAVE ANY OTHER MEDICAL ISSUES, ALLERGIES OR SYMPTOMS THAT WE SHOULD KNOW ABOUT?

...

LIMITATIONS

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

RISKS & COMPLICATIONS

Adverse effects from Intravenous Nutrition Therapy include but are not limited to:

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

I, the Client, represent that I am at least 18 years of age, have read and understand this release form, and am competent to exercise this agreement.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE
If 'AGREE' is selected and the client is younger than 18yrs old, a guardian MUST fill in the following step.

PLEASE CHECK AGREE OR DO NOT AGREE IF UNDER 18 YEARS OLD
AGREEI DO NOT AGREE

PLEASE TYPE YOUR FULL NAME (BY GUARDIAN) (required)

DATE (BY GUARDIAN) (required)

...

CONSENT

I certify that :

- I have read and fully understood the above paragraphs and discussed the risks, benefits and alternatives to this treatment
- I have had sufficient opportunity for discussion and to ask questions.

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

I have had time to consider the treatment :

PLEASE CHECK AGREE OR DO NOT AGREE (required)
AGREEI DO NOT AGREE

...

PLEASE TYPE YOUR FULL NAME (required)

DATE (required)