I, the parent/guardian make oath and say that I am the lawful guardian of the child listed above and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.
I give consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.This consent will remain in effect until it is revoked by notifying my child’s medical, mental health care and insurance providers in writing, and the Agent named above that I wish to revoke it.Any questions or concerns regarding this authorization may be directed to me.I give consent for The Hydrate Bar to provide IV infusion therapy sessions for my child and take full responsibility for my child and am aware of the risks and benefits that Iv infusion therapy provides.
Thank you for your time and business. Have a wonderful day and enjoy your IV infusion drip.