ALDRJOY IV HYDRATION HEALTH AND WELLNESS, LLC
INTRAVENOUS THERAPY CONSENT
I hereby authorize the administration of intravenous vitamins, minerals, and other nutrients to me. I understand that the foregoing procedure involves inserting a needle into one of my veins and injecting a solution composed of various nutrients.
Alternatives to this procedure are oral supplementation and dietary and lifestyle changes.
The principal side effects that may accompany intravenous administration of nutrients include:
• discomfort, burning, bruising, and stinging at the site of infusion or if IV infiltrates into surrounding tissue;
• muscular spasms, weakness, or fatigue;
• inflammation of the vein used for injection, phlebitis, 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.