IV Therapy Consent Form: Draft Review Pack

Rewritten consent form, a summary of every change, and the open questions we need answered before this can be used with patients.

This is a draft. Not for patient use.

Nothing here should be printed or signed until Dr Patel's attorney has reviewed it and the questions below are answered. Every page of both PDFs is stamped DRAFT for that reason.

The documentsBoth PDFs are Letter size and print ready

Patient facing

IV Therapy Informed Consent

Four pages. The form a patient reads and signs. Includes a per encounter treatment table, mobile visit acknowledgment, and an optional photography release kept separate from care.

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Internal, do not send to patients

Revision Summary and Open Items

Three pages. What changed and why, the questions for Dr Patel with space to write answers, and where a Florida attorney should focus.

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Questions for Dr PatelItems marked BLOCKS USE must be answered before any patient signs

Ten items. The first four are the ones that matter most, and three of them are one line answers.

  1. Florida medical license number Blocks use Printed on the form as the supervising physician of record.
  2. Which address is the practice address Blocks use The form now uses The DeSota, 1451 2nd Street, Sarasota FL 34236, taken from the license agreement. The website still says 2100 S Tamiami Trl. One of the two needs to change, and the form should match whatever patients are told.
  3. Who starts the IV, and is the physician on site Blocks use RN, LPN or paramedic, and whether the physician is physically present or reachable under written standing orders. This decides the supervision wording. The form also promises the clinician will monitor the patient during treatment, so we need to know whether staff ever leave during an infusion on a mobile visit.
  4. Is the main line answered after hours Blocks use The form currently sends post treatment symptoms to (863) 838-7825. If that line is not answered after hours we need a different number, because delayed reactions are the ones that matter.
  5. What is carried on a mobile visit Before printing Epinephrine, oxygen, diphenhydramine, blood pressure monitoring. The mobile acknowledgment should be consistent with what is actually in the bag. We deliberately kept this out of the patient form so it does not become a promise checked at every visit.
  6. Compounding pharmacy name and location Before printing Only if compounded additives are used. Also whether it is a 503A or 503B facility.
  7. Standard drip menu with doses Before printing Lets us pre print the common formulations instead of handwriting every additive at the chairside, which is where transcription errors happen. If the menu includes high dose vitamin C, G6PD screening becomes a standing orders question.
  8. Does a Notice of Privacy Practices exist The form says one was offered, so the document needs to exist and be available to hand over.
  9. Will the practice treat patients under 18 If so, the representative signature block needs Florida specific consent authority language.
  10. Has the malpractice carrier been asked to review the form Most carriers review a consent form at no charge and some require it. It is the cheapest review available and worth doing alongside the attorney.

What changed from the original draft

HighPer encounter treatment table. Records the fluid, additives and doses, rate, site, supervising physician and who administered. The original authorized unnamed additives, which is the gap a plaintiff attorney works with.
HighEmergency routing corrected. Chest pain and shortness of breath appeared in both the call the practice list and the call 911 list. They now appear only under 911.
HighMobile visit acknowledgment. Discloses limited emergency equipment, different sterile conditions and longer EMS response at a home, hotel, office or boat. The original described only an outpatient setting.
HighAfter hours contact and red flag symptoms. Delayed reactions are common and the original gave patients nowhere to go.
MedEmergency intervention authorization covering emergency medications and activating EMS, plus a note that ambulance charges are separate.
MedOff-label and compounded product disclosure, since most vitamin infusions are not FDA approved for the purposes they are given for.
MedThrombosis and air embolism added to the insertion risk list. Both are standard on hospital consents.
MedPregnancy and breastfeeding upgraded from a checkbox to a real warning, and a post treatment warning added against driving.
LowPhotography release separated into an optional opt-in block with its own signature, so it is no longer bundled into consent to treatment.
LowPlain language rewrite, larger type for older patients, branded layout, form version and page numbers.
One correction worth knowing about. Four AI models reviewed this form. Two of them stated that Florida law requires the consent to be witnessed by someone who is not an employee of the physician, and called its absence a fatal defect. We read the statute directly. Fla. Stat. 766.103 contains no witness requirement. Both models had most likely borrowed the rule from Florida's advance directive statute, which is a different law. No witness block was added. If the attorney or the carrier wants one for evidentiary comfort that is a reasonable choice, but it is a preference rather than a legal requirement.