Complete the Consent Form

I have informed my healthcare professional of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed my healthcare professional of my medical history.

I understand and acknowledge that: intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease; and IV infusions are not a substitute for my physician’s medical care.

I understand that the following may reduce the efficacy of IV Infusion Therapy: cigarette smoking; caffeine consumptions (increases vitamin C excretion); poor die (processed foods, high sugar intake, nutrient deficient diets); heavy metal toxicity

I understand the procedure involves inserting a needle into a vein and injecting the prescribed solution. I am also aware there are alternatives to intravenous therapy, such as oral supplementation and/or dietary and lifestyle changes.

a. Occasionally: Discomfort, bruising and pain at the site of injection, a fall in blood pressure (staff will stop the infusion and provide IV fluids to help it return to normal).
b. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
c. Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
d. Long-term adverse consequences of these therapies may be possible but are unknown at this time. IV therapy is not FDA-approved to treat or prevent any illness or disease.

I am aware that other unforeseeable complications could occur. I do not expect my Healthcare Professional to anticipate and or explain all risks and possible complications. I rely on my healthcare professional to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have my questions answered.