IV Therapy and Injections Consent

Captures the patient's signature, contact details, an emergency contact and a health questionnaire covering allergies, medications and history. Designed for clinics and nursing staff giving drips or injections.

Use this template

In the Claude connectors directory

Patient name

Date

Consent statement

Signature

Sign here

Patient details

Name

First Name

Last Name

Personal information

Date of birth

Home address

Address details

City

Postal code

Mobile number

Email

Contact details

Emergency contact

Emergency contact phone

Health questionnaire

Why are you seeking treatment?

Have you had IV therapy before? If so, what type and how long ago?

Have you had any problems with IV therapy or injections?

List any past or current medical conditions

Any history of heart or lung problems?

Have you ever been diagnosed with high blood pressure?

Any history of kidney problems?

Any history of liver problems?

List any past surgical procedures

List all medications, supplements or vitamins you take

Have you ever had an allergic reaction to a medication?

Are you allergic to sulfur?

Are you or could you be pregnant?

Are you currently breastfeeding?

Any history of cancer?

Final declaration

Patient signature

Sign here

Today's date

Nurse signature

Sign here

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