Essential Me, LLC

INTRAMUSCULAR NUTRIENT INJECTION CONSENT

I hereby authorize the administration of intramuscular vitamins, minerals, and other nutrients to me. I understand that the foregoing procedure involves inserting a needle into one of my muscles and injecting a solution composed of various nutrients.

I consent to all nutrient injections rendered by the doctor, medical assistants, or nurses employed by Essential Me, LLC. I do not expect the persons employed or associated with Essential Me, LLC to anticipate and or explain all risk and possible complications. I hereby release the doctors at Essential Me, LLC from all liabilities regarding my treatment with vitamin and nutrient injections.

Alternatives to this procedure are oral supplementation and dietary and lifestyle changes.

The principal from all effects that may accompany intramuscular administration of nutrients include but not limited to:

• Pain and bruising at the injection site, allergic reactions, headaches, dry month, difficulty sleeping, diarrhea, blurred vision, unpleasant taste
• Increased urination, cramps, and metabolic disturbances
• inflammation or infection at the injection site, metabolic disturbances, and injury (rare); and severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death (extremely rare).

Other unforeseeable complications could occur. This procedure may be considered medically unnecessary.

I understand that I have the right to consent to or refuse any procedure at any time prior to its performance. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed procedure. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from this procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I am aware that unforeseeable complications could occur, and I do not expect you to anticipate and explain all possible risks and complications. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

I hereby instruct you to perform the procedure and agree to the above release. I also verify that all information presented to you in my medical history is true to the best of my knowledge, and that I am not misrepresenting myself.

I hereby acknowledge that this is a self-pay service, no medical insurance is accepted, and all payments are non-reimbursable. I agree to be responsible for payment at the time of service for all services, including non-covered services.