INFZD Hydrate — Patient Intake & Consent

1Patient Information

Full name

Date of birth Date of service

Phone Email

Emergency contact & phone Primary care provider (name & phone)

2Nature of Services & Disclaimer

INFZD Hydrate provides elective IV hydration, vitamin/nutrient infusions, and intramuscular (IM) injections for general wellness and nutritional support, provided by or under the supervision of a licensed Family Nurse Practitioner with full practice authority in Illinois.

These are wellness services. They are not intended to diagnose, treat, cure, or prevent any disease, and are not a substitute for care from your physician. Individual ingredient statements have not been evaluated by the FDA; some ingredients are used off-label.

I understand these are elective wellness services and not a substitute for medical care.

3Service(s) Requested

Select any you're interested in. Your provider will confirm what's appropriate for you before administration.

The Everyday Hero Vitamin & nutrient blend The Reset Button Recovery & rehydration — contains Rx (ondansetron, ketorolac) The Shield Immune support blend The Champion Performance & recovery blend The Torch Metabolism & energy blend NAD+ Therapy (IV) Cellular energy & anti-aging NAD+ (IM injection) 50 mg, up to 3x/week Liquid Gold Postpartum / breastfeeding support The Grace Period Perimenopause & menopause support Inner Beauty Skin & hair blend Snow Bright Brightening & anti-aging (high-dose antioxidants) The Zen / PICO Broad-spectrum CBD infusion Add-ons / boosters requested

4Medical History & Screening

Your honest answers protect your safety. Please answer every item, then explain any “Yes” below.

Allergies to medications, foods, latex, or a prior IV / injection reaction YesNo

Kidney disease, reduced kidney function, or dialysis YesNo

Heart failure, heart-rhythm problems, or known long-QT syndrome YesNo

High or low blood pressure, or fainting with needles / blood draws YesNo

Bleeding disorder, easy bruising, or blood thinners / anticoagulants YesNo

Ulcers, GI bleeding, or aspirin / NSAID sensitivity or NSAID-triggered asthma YesNo

G6PD deficiency (glucose-6-phosphate dehydrogenase deficiency) YesNo

Diabetes or history of low blood sugar YesNo

Liver disease, thyroid disease, or history of cancer YesNo

Currently pregnant, planning pregnancy, or breastfeeding YesNo

Currently taking any medications or supplements (incl. CBD, sedatives) YesNo

Please list your current medications & supplements (with doses) Please explain any “Yes” answers above (conditions, allergies, symptoms)

5Procedure, Risks & Acknowledgment

IV therapy delivers fluids and nutrients through a small catheter placed in a vein; IM therapy is an injection into a muscle. A trained provider will prepare the site and monitor you during and after your session (roughly 30 minutes to 4 hours depending on the service; NAD+ is infused slowly).

General risks

Pain, bruising, bleeding, or swelling at the site
Vein inflammation (phlebitis) or fluid leaking into tissue (infiltration)
Infection or, rarely, cellulitis
Lightheadedness or fainting (vasovagal reaction)
Allergic reaction — mild to, rarely, severe anaphylaxis
Fluid overload or electrolyte imbalance (esp. with heart or kidney conditions)
Very rarely, air embolism or blood clot

Ingredient-specific

High-dose Vitamin C, ALA & Glutathione can cause red-cell breakdown in G6PD deficiency (screening required)
Ketorolac (Toradol) in The Reset Button — not for NSAID/aspirin allergy, ulcers/GI bleed, significant kidney disease, bleeding risk, or pregnancy
Ondansetron may rarely affect heart rhythm (QT) with other QT-affecting drugs
Magnesium/Calcium can cause flushing or lower blood pressure
NAD+ can cause chest tightness, flushing, nausea, or cramping if infused too quickly
Biotin & B-vitamins can interfere with lab tests (thyroid, troponin) — tell any lab you received them

I have read and understand the risks above, including those specific to the service(s) I selected, and my questions have been answered. If I selected a service containing prescription medication (e.g., The Reset Button), I consent to receive it if my provider determines it is appropriate.

6Pregnancy & Breastfeeding

Some ingredients are not recommended in pregnancy. Please select one.

Not pregnant / not breastfeeding Breastfeeding Possibly pregnant Not applicable

7Consent, Financial & Privacy

Alternatives & results: Alternatives include oral hydration, oral vitamins, dietary changes, rest, or declining treatment. Results vary and no specific outcome is guaranteed. I may withdraw consent at any time.

I voluntarily consent to the IV/IM service(s) I selected, authorize INFZD Hydrate staff to administer them and to take reasonable emergency measures (including calling 911) if needed, and confirm I am at least 18 years old. I understand these are out-of-pocket services generally not covered by insurance, payment is due at time of service, and fees for services rendered are non-refundable. I acknowledge my health information will be handled per applicable privacy laws and INFZD Hydrate's Notice of Privacy Practices (available on request).

Photo / media release (optional)

I grant permission for INFZD Hydrate to use photos/videos of my session for marketing/social media. I do not grant permission.

8Electronic Signature

By typing my name below, I am signing this form electronically and confirm I have read and understand it.

Type your full legal name Date